Rehabilitation of the Spine: A Practitioner's Manual

I I DVD Index Note: Throughout the DVD when a common dys function is contrasted with normal func tion-either durin...

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DVD Index

Note: Throughout the DVD when a common dys function is contrasted with normal func tion-either during a test or exercise-the Pain icon will be shown as a visual cue sig nifying that the dysfunction represents a "weak link" which can cause biomechanical overload and eventual pain.

•

Dead Bug Floor o Half Foam o Full Foam McGill's Abdominal Curl Up Superman Wall Ball Hamstring Curls Balance Training o Rocker Board Push-Up with Plus Deep Neck Flexors Scapulo-Thoracic Facilitation

• • • • •

• • •

•

Introduction I. Physical Perfonnance Evaluation • Vele Forward Lean • 1 Leg Standing Balance • Squat • One Leg Squat • Vleeming Hip Flexion • Janda Hip Extension • Janda Hip Abduction • Side Bridge Endurance • Wall Angel • Respiration • Push-Up • Arm Abduction • Neck Flexion

n. Sparing Strategies Micro Breaks o McGill Overhead Arm Reach o Brugger's Postural Relief Position Hip Hinge Advice o Sit to Stand o Standing o Putting on Socks o Putting on Shoes Psoas Stretch Mid-Thoracic Extension Mobilization o Foam Roll: Supine o Foam Roll: Upper Back Cat o Foam Roll: Horizontal Back Stretch Health Club Tips o Hamstring Curl o Hip Extension Multi-Hip Machine o Hip Abduction Multi-Hip Machine o Rowing o Hanging Leg Raise o Incline Sit Ups o Seated Abdominal Crunch o Lat Pull Down & Lateral Raises o Sit Up o pec Dec & Sit Up III. Stabilizing Strategies • Functional Bracing • Quadruped o Cat Camel o Bracing o Quadruped Leg Raise o Quadruped Arm Leg Raise (Bird Dog) • Side Bridge o On Knees o On Ankles o Roll Over

IV. Functional Integrated Training (FIT) Squats o With Ball o Facing Wall o Back to Wall o Wall Slide (Angel) o 1 Leg Squat Facing Wall Lunges o Vele/Janda Forward Lunge Step o Forward Lunge o Angle Lunges with Reach (Push) o Angle Lunges with Pull

•

Functional Reaches o Star Reaches o Running Man Pulley-Pushes o Punch with Step o Punch with Trunk Twist & Shoulder Internal Rotation o Weight Shift o Forehand o Throw o Volleyball Spike o Overhead Pull Down • Standing • 1 Arm (2 Leg or 1 Leg) Kneeling Pulleys-Pulls o Backhand Dynamic o Golf Swing Static o Weight Shift o Pull with Trunk Twist and Shoulder External Rotation o PNF Sword o PNF Seatbelt o Lawn Mower Core Resistance o Dead-Bug Resistance with Stick •

•

•

o o

o

Squat with Stick Bosu • with Manual Resistance • with Stick Core Twist

V. Czech School of Manual Medicine • Jiri Cumpelik-Spinal Exercises o Ready-Supine Position o Supine Position with Legs Semi-Flexed o Supine Twist-Supine Position with Legs Flexed and Lifted Side Lying The Sphinx o The Cobra Pavel Kolar-Developmental Kinesiology o Postural Ontogenesis o o

•

First Homolateral Pattern, e.g. the Development of Grasping Supine o Reflex Locomotion • Reflex Turning o The Deep Stabilizing System of the Spine • Palpation of Lateral Group of the Deep Abdominal Muscles • The Deep Stabilizing System of the Spine-Treatment o Examination and Mobilization of the Lumbar Spine Karel Lewit-Mobilization, Soft Tissue and Relaxation Techniques o Mobilization of the Fascia on the Back in a Cranial Direction o Mobilization of the Fascia on the Back in a Caudal Direction o Palpation of the Pelvic Floor o PIR: Pelvic Floor Plus M. Transversus Abdominis Examination and Mobilization of the Thoracic Spine into Extension o Mid Thoracic Spine Self Mobilization Dagmar Pavlu-Brugger Concept o The Agistic-Eccentric Contraction to Influence the Fingers Flexors o Agistic-Eccentric Contraction Influence the Wrist Flexors o Thera-Band Exercises to Improve Function of the Thigh Adductors and Plantar Flexors and Supinators of the Foot o "Great" Combined Exercise with a Thera-Band o Activities of Daily Living Misa Veverkova-Sensory Motor Stimulation/Movement Pattern Assessment o Sensory Motor Stimulation Sta bility Test Standing on One Leg • Standing on One Leg with Eyes Closed • Standing on One Leg on a Firm Mattress Standing on One Leg on a Firm Mattress with the Eyes Closed o The "Small Foot" Passive Modeling of the "Small Foot" • Modeling the Small Foot with Patient's Cooperation Active Small Foot Exercise o Balance Sandals • Sensory Motor Stimulation Walking with Balance Sandals • Walking Under Supervision • Walking by Oneself o Hip Extension Movement Pattern • Movement Pattern Assessment-Motor Stereotype of Hip Extension • Motor Stereotype of Hip Extension Walking o Arm Abduction Movement Pattern •

o

•

•

Second Edition

Rehabilitation of the Spine A Practitioner's Manual

THIS PAGE INTENTIONALLY LEFT BLANK

Second Edition

Rehabilitation of the Spine A Practitioner's Manual Craig Liebenson, Editor

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t=l- Lippincott Williams & Wilkins a

Wolters Kluwer business

Pnilfil�phiOi • hilimoft • New Yorl· Loodon Buenos Airts· �g Kong· 5ydrwy· Tokyo

Acquisitions Editor: Pete Darcy Managing Editor: Laura Horowitz Marketing Manager: Christen Murphy Production Editor: Christina Remsberg Designer: Risa Clow Compositor: Circle Graphics Printer: Quebecor-Taunton Copyright © 2007 Lippincott Williams & Wilkins 351 West Camden Street Baltimore, MD 21201 530 Walnut Street Philadelphia, P A 19106 All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system with out wrillen permission [Tom the copyright owner. The publisher is not responsible (as a matter of product liability, negligence, or otherwise) for any injury resulting [Tom any material contained herein. This publication contains information relating to general prin ciples of medical care that should not be construed as specific instructions for individual patients. Manufac turers' product information and package inserts should be reviewed for current information, including contraindications, dosages, and precautions.

Printed in the United States ofA merica First Edition, 1996

Library of Congress Cataloging-in-Publication Data CIP data has been requested and is available from the Library of Congress.

The publishers have made every effort tently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 824-7390. International customers should call (301) 714-2324. Visit Lippincott Williams & Wilkins on the Internet: http://www.LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, E ST. 06 1

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Dedication

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To my wife, Deannie, who has sacrificed much so that this book could see the light of day.


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Foreword

It is a pleasure and a privilege to welcome the sec

mean we should all become rehabilitation special

ond edition of

ists: rather, it goes to the heart of what health care

Rehabilitation of the Spine.

It is diffi

cult to believe that nearly 10 years have passed since the first edition. So much that seemed revolu tionary then is now accepted as the standard for good back care, and Liebenson's textbook has become a classic.

is all about. The basic approach of this book remains the same. It updates the evidence base for an active approach, integrates it with clinical experience, and shows how it can be applied to routine practice. Every

The goal remains to improve clinical management

chapter is completely re-written and there are many

of spinal pain; more specifically, to integrate relief

distinguished new authors. The new format incor

of symptoms with restoration of function. There is

porates modern teaching aids and a DVD. Ten years

now broad agreement on the importance of rehabil

on, the philosophy is more developed and more

itatiop. and the need to improve functional and occupational outcomes. There is al so growing

mature, but it remains true to the original. We are now more confident that we really can improve clin

recognition that rehabilitation is not a separate,

ical management of spinal pain: the challenge

second-stage intervention after "proper" treatment

remains to deliver that to every patient with spinal

has no more to offer yet recovery remains incom

pain. I am confident this new edition will continue

plete. Rather, rehabilitation should be an integral

to deliver that message and help to make it a reality.

part of good clinical management. Every health professional who cares for these patients should

Gordon Waddell, MD, F R C

accept at least some responsibility for their func

Western Infirmary

tional and occupational outcomes. That does not

Glasgow, Scotland

vii


I

Preface

I

In the 10 years that h ave passed since this book's first

Part I: Overview introduces readers to the new

edition w as published, rehabilitation for p atients with

p ar adigm.

activity-limiting p ain of spinal origin h as become the st andard of c are. The l atest scientific evidence h as identified patient reassur ance and reactivation as the first steps in the self-man agement journey. A team approach involving p atients, he alth c are providers, employers, and p ayors all working together is needed to alter the course of distressing or dis abling b ack and neck pain. Rehabilitation of the Spine,

Second Edition, sheds light on v arious i atrogenic risk f actors of current pr actice approaches, in particular, the routine recommendation of bed rest, excessive diagnostic testing, overpresCliption of n arcotic anal gesics, and in appropri ate selection criteria for spinal surgery. With new preemptive societal measures, via the Internet and m ass media, providing the momen tum, this book hopes to offer a practical manual for heal th c are providers to shift towards a confident, empathetic, self-m an agement approach to spinal disorders.

A New Paradigm A new strategy utilizing the mass media to educate

Part II: Basic Science covers the mechanisms of injury, restabilization, and p ain. Part III: Assessment covers di agnostic triage, functional assessment, psychosocial screening, and outcomes m an agement. Part IV: Acute Care Management outlines the modem approach for m an aging the acute phase of spine disorders. Part V: Recovery Care Management focuses on the tools and techniques needed for recovery, including such topics as sensory-motor tr aining, yoga, func tional st ability tr aining, cognitive-beh avioral train ing, and nutrition. Part VI: Practical Application by Region contains a Visual Atlas of key assessment and tr aining tech niques designed to give the re ader the full l and scape and context of key reh ab "tools of the tr ade." Part VII: Implementing the Functional Paradigm sums up the book by covering implementation of the new p ar adigm in pr actice.

consumers directly about the positive benefits of physical activity and the d angers of deconditioning h as been undert aken in both Austr alia and Scotland. This book supports this approach by giving he alth c are providers a guide to the modern principles of evidence-b ased, outcome-b ased, p atient-centered, functional, and active self-care for p atients suffering dis abling musculoskelet al spinal p ain. M any of the architects of this new p ar adigm Steven Linton, Stuart McGill, and Nikol ai Bogduk h ave been added as contributors to this second edition to distill the new literature into a practical fr amework. Accordingly, each and every chapter h as been entirely re-written. However, the book's b asic premise of focusing on active c are, outcomes, and psychosocial f actors rem ains unchanged.

Organization The book's organization is similar to the first edi tion, with the most signific ant addition being a new regional application section (Part V I).

Pedagogical Features Icons: An icon system h as been designed for this second edition to guide re aders to essenti al topics. You will find these icons highlighted on the chapter openers, and they will let you know what topics will be covered.

" 4'

•

Di agnosis

Function al evalu ation

Cl assific ation ix

x

--

Preface

• .ll �.�

•

·(It,, ..

fa 'l�

Design: The second edition has been completely redesigned. The hierarchy of the content is more clearly delineated, and the special features are Psychosocial factors

easier to find and access.

Accompanying DVD Reassurance

To support the hundreds of illustrations of assess ment and self-care techniques, a DVD is included to better demonstrate the correct application of the

Pain

most important methods. A DVD icon

(----""

.

"

()

in the

book indicates methods that are shown on the DVD. Some of the methods included are: •

Reactivation

Reconditioning

Vleeming's active straight leg raise test

•

McGill's side bridge endurance test

•

Hip hinge advice

•

Brugger's micro-break

•

A bdominal bracing

•

Lewit's examination and mo bilization of the thoracic spine

Learning objectives: Each chapter starts with a list

Vojta's basic reflex locomotion positions

of Learning O bjectives to emphasize the most

•

relevant information in the chapter.

•

Balance sandal training

Audit Process: Each chapter ends with an Audit

•

Star lunges

Process box-a self-check of the learning o bjectives.

•

Functional training with pulleys

Clinical Pearls: This special feature is found throughout the book and contains "pearls" of wisdom from experienced practitioners. Practice-Based Problems: Found in many chap ters, these boxes present common clinical dilemma encountered in practice, wherein clinical decision making is highlighted. Illustrations: The second edition utilizes a highly illustrative presentation style, and many new line drawings and photographs have been added.

Rehabilitation of the Spine is a practical guide book for identification of reha bilitation candidates and solutions. Hopefully, restoring function in the loco motor system will become the. standard of care for managing patients with complex neuromusculo skeletal disorders.

Craig Liebenson Los Angeles, Califomia

I

Acknowledgments

I have had the good fortune to have had my chiro practic education complemented by an introduc tion to a broader paradigm of care, Many conversations with one of the grandfathers of spinal surgery and pioneers of taking a functional view of spinal problems William Kirkaldy-Willis helped sharpen this author's view of the locomotor system.

In the mid 1980s I was fortunate to begin my studies with the great Czech neurologists and manual medicine practitioners, Karel Lewit and Vladimir Janda. This laid the groundwork for inte gratin6 rehabilitation with manipulative therapy. In particular, they have contributed to our approach, a comprehensive analysis of the locomotor system, which enables clinicians to see how various func tional pathologies such as stiff joints, thigh mus cles, and weak muscles are all part of a chain of events amendable to a specific prescription of manipulation and rehabilitation. In the late 1980s another great pioneer, from San Francisco, Dennis Morgan showed me how spine stabilization training had sprung forth from P.N.F .. Stabilization training has spread around the world, and I have been fortunate to have had the chance to spend a great deal of time over the last decade with Pro Stuart McGill one the preeminant researchers of the spine stability system. In the past few years, I have begun visiting him at the University of Water-

I 100 where many of the ideas of Pro Janda and Den nis Morgan are being researched with "state of the art" biomechanical and neuropsychological tech niques. Institutions such as the Los Angeles College of Chi ropractic, Anglo-European College of Chiropractic, and Charles University, and organizations such as Chiropractic Education of Australia have all con tributed greatly to this work through their support of educational programs designed to expand the musculoskeletal paradigm to include a more func tional, biopsychosocial approach to rehabilitation of the locomotor system. Certainly, I could not have accomplished this task without the tremendous support of Dr.'s Sylvia Deily and Tanya Broaded in proo[Teading and com menting on hundreds upon hundreds of manuscript pages. My first and second edition editors, Linda Napora, Laura Horowitz, and Christina Remsberg under the stewardship of Pete Darcy have bee a reg ular source of support and encouragement driving me on to the finish line. My photographer Howard Linton and artists Jiri Hlavaeek and Joseph DePinho have done exceptional work, along with my amaz ingly patient and persistant videographer and DVD editor Robert Fisher. Craig Liebenson Los Angeles, California

Xl


Contributors

Charles Aprill, MD

Scott Fonda, DC

New Orleans, LA

Rehabilitation Institute of Chicago

Cindy Bailey, DPT, ATC

Chicago, Illinois

Associate Professor of Clinical Physical Therapy

Clare Frank, DPT

University of Southern California

Back in Balance Physical Therapy

Los Angeles, CA

Kaiser Permanente Orthopedic Physical Therapy

Nikolai Bogduk, PhD Professor of Pain Medicine, University of Newcastle Head, Department of Clinical Research, Royal Newcastle Hospital, Newcastle,

Residency and Movement Science Fellowship Los Angeles, CA

Michael C. Geraci, Jr., MD, PT Buffalo Spine and Sports Institute

New South Wales, Australia

Buffalo, New York

Jennifer Bolton, PhD

Natalie Gluck-Bergman, DC

Anglo-European College of Chiropractic

Los Angeles, CA

Bournemouth, England

Steve Heffner, DC

Mark R. Bookhout, PT

Williamsport, PA

Physical Therapy Orthopaedic Specialists

Alena Herbenova, PhD

Minneapolis, MN

Institute for Postgraduate Medical Education

Alan Breen, DC, PhD Institute ror Musculoskeletal Research and Clinical Implementation

Charles University Prague, Czech Republic

Helena Hermach, PT

Anglo-European College or Chiropractic

Cmund, Austria

Bournemouth, UK

Paul W. Hodges, BPhty(Hons) PhD, MedDr

Wendy Burke, DPT

Professor and NH MRC Senior Research Fellow

Assistant Professor of Clinical Research

Division of Physiotherapy

University of Southern California

The University of Queensland

Department of Biokinesiology and Physical Therapy

Brisbane, Australia

Department of Orthopaedic Surgery

Gary Jacob, DC, LAc, MPH

Los Angeles, CA

Los Angeles, CA

Micheal A. Clark, DPT

Vladimir Janda, MD

National Academy or Sports Medicine

Former Chief, Department of Rehabilitation

Calabasas, CA

Medicine in Prague

Jonathan Cook, DC Anglo-European College of Chiropractic Bournemouth, UK

Neil Craton, MD Assistant Professor, Ul1iversity of Manitoba, Faculty of Medicine Director, Legacy Sport Medicine Winnipeg, Manitoba Canada

Jin

Cumpelik, PT

Faculty of Physical Education and Sport Faculty o{Dance, Academy of Pelforming Arts Charles University Prague, Czech Republic

George DeFranca, DC W. Boylston, MA

Postgraduate Institute of Medicine University Hospital Prague, Czech Republic

Gwendolen A. Jull, PT, PhD Head of Division of Physiotherapy School of Health and Rehabilitation Sciences The University of Queensland Brisbane, Australia

William H. Kirkaldy-Willis, MD, BChir, FRCS (E and C), FACS, LLD (Hon), FICC (Han) Emeritus Professor of Orthopaedic SurgelY Royal University Hospital University of Saskatchewan Saskatoon, Saskatoon Canada

Alena Kobesova, MD 2nd Medical Faculty

Sylvia Deily, DC

University Hospital Motol

Los Angeles, CA

Charles University, Prague, Czech Republic

XIII

xiv

--

Contributors

Pavel Kolar, PaedDr

Maria Perri, DC

2nd Medical Faculty

Highland Mills, NY

University Hospital Motol

Sibyle Petak-Krueger, PT


Martin Lambert, PT Buffalo, NY

Switzerland

Charles Poliquin Poliquin Performance Center

Ellen Lee, PhD

Tempe, AZ

School of Physical Therapy

Joel Press, MD

Texas Woman's University Houston, Texas

Medical Director, Spine and Sports Rehabilitation Center Rehabilitation Institute of Chicago

Karel Lewit, MD, DSc

Chicago, IL

2nd Medical FaculLy

David R. Seaman, DC

University Hospital Motol Charles University, Prague, Czech Republic

Craig Liebenson, DC Los Angeles Sports and Spine Los Angeles, CA

Steven J. Linton, PhD brebro University Department of Behavioral, Social and Legal Sciences Psychology brebro, Sweden

Leonard Matheson, PhD Washington University School of Medicine St. Louis, MO

Stuart M. McGill, PhD Professor of Spine Biomechanics Faculty of Applied Health Sciences Department of Ki nesiology

Palmer College of Chiropractic Florida Port Orange, FL

Maureen J. Simmonds, PhD, PT School of Physical and Occupational Thel-apy McGill University Montreal, Quebec, Canada

Clayton Skaggs, DC Central Institute for Human Performance St. Louis, MO

John J. Triano, DC, PhD, FCCS(c) Texas Back Institute Plano, TX

Pamela Tunnell, DC Ri dgefield, CT

Marie Vavrova, PT Prague, Czech Republi c

University of Waterloo, Canada

Frantisek Vele, MD, PhD

Robin McKenzie, PT

Faculty of Physical Education and Sport

President McKenzie Institute International


Raumati Beach, New Zealand

Howard Vernon, DC, PhD

Vert Mooney, MD

Director, Center (or the Study of the Cervical Spine

Clinical Professor Orthopaedics

Canadian Memorial Chiropractic College

University of California, San Di ego

Toronto, Ontario, Canada

Medical Director of Spine & Sport Centers

Michaela Veverkova, PT

San Diego, CA

Institute for Postgraduate Medical Education

Donald R. Murphy, DC

Prague, Czech Republic

Rhode Island Spine Center

Robert Watkins, MD

Providence, RI

Los Angeles Spine Surgery Institute

Chris Norris, PT

Professor of Clinical Orthopaedic Surgery

Manchester, UK

Neil Osborne, DC, FRSH, FCC(Orth) Anglo-European College of Chiropractic Bournemouth, UK

Dagmar Pavlu, PaedDr, PhD Faculty of Physical Education and Sport Charles University Prague, Czech Republic

University of Southern California Los Angeles, CA

Steven Yeomans, DC Yeomans-Edinger Chiropractic Center Ripon, WI

Contents

PART IV ACUTE CARE MANAGEMENT

PART I OVERVIEW

1. Active Care: Its Place in the Management of Spinal Disorders- Crai g Liebenson

3

2. The Role of Muscles, Joints, and the Nervous System in Painful Conditions of the Spine

Craig Liebenson

30

Problem and Modern Attempts to Manage It

51

Steve Heffner

Craig Liebenson

-

16. Brugger Methods for Postural Correction

Vladimir Janda

72

Maria Perri

5. Lumbar Spine Stability: Mechanism of Injury and Restabilization-Stuart M. McGill

93

6. The Sources of Back Pain-Nikolai Bogduk

1 12

125

S. Outcome Assessment-Steven Yeomans, Craig Liebenson, Jennifer Bolton, and Howard Vernon

9. Assessment of Psychosocial Risk Factors of C raig Liebenson Chronicity-"Yellow Flags "-

183

Appendix 9A Yellow Flag Form

Ability-Craig Liebenson and

and Charles Poliquin

460

Model of Assessment and Outcome

Maureen J. Simmonds and Ellen Lee

260

13. Employment Screening and Functional Capacity Evaluation to Determine Safe Return to Work-Leonard Matheson and

Tension-Michael C. Geraci, Jr.,

Martin Lambert, and Mark R. Bookhout

464

21. Manipulation Techniques for Key Joints 487

511

22. Sensory Motor Stimulation-V ladimir Janda, Marie Vavrova, Alena Herbenova, and Michaela Veverkova

226

12. Physical Performance Tests: An Expanded

276

Appendix 19A The Role of Active Release Technique in Rehabilita t ion- Clayton Skaggs

(AFTER 4 WEEKS)

203

11. Quantification of Physical Performance

Vert Mooney

407

PART V RECOVERY CARE MANAGEMENT

Vladimir Janda, Clare Frank, and

Steven Yeomans

403

and Natalie Gluck- Bergman

George DeFranca

201

10. Evaluation of Muscular Imbalance Craig Liebenson

Helena Hermach

and Treatment of Adverse Neurodynamic

169

and Steven Yeomans

388

20. Neuromobilization Techniques-Evaluation

146

Appendix SA Forms

Alena Kobesova

Appendix ISA Exteroceptive Therapy

Liebenson, Pamela Tunnell, Donald R. Murphy,

7. Diagnostic Triage in Patients with Spinal Pa in-Neil Craton

369

IS. Soft Tissue Manipulation-Karel Lewit and

19. Manual Resistance Techniques-Craig

123

PART III ASSESSMENT

352

17. Rehabilitation of Breathing Pattern Disorders

91

PART II BASIC SCIENCE

and Charles Aprill

330

Dagmar Pavlu, Sibyle Petak-Krueger, and

4. Putting the Biopsychosocial Model Into Practice

15. McKenzie Spinal Rehabilitation Methods G ary Jacob, Robin McKenzie, and

3. Quality Assurance: The Scope of the Spine Craig Liebenson

293

(FIRST 4 WEEKS)

14. Active Self-Care: Functional Reactivation for Spine Pain Pati ents- Crai g Liebenson 295

5 13

23. Facilitation of Agonist-Antagonist Co-activation by Reflex Stimulation Methods-Pavel Kolar

53 1

24. Yoga-Based Training for Spinal Stability Jiri Cumpelik and Frantisek Vele 566 25. Spinal Segmental Stabilization Training Paul W. Hodges and Gwendolen A. Jull

585

xv

xvi

--

Contents

26. Functional Stability Training

34. Integrated Approach to the Lumbar Spine

612

Craig Liebenson

Craig Liebenson, Scott Fonda,

Appendix 26A Proprioceptive Taping-An Adjunct to Treating Muscle Imbalances

35. Integrated Approach to the Cervical Spine

Clare Frank, Wendy Burke, and Cindy Bailey

798

and Sylvia Deily

Craig Liebenson, Clayton Skaggs, Scott Fonda,

663

852

and Sylvia Deily

27. Global Muscle Stabilization Training Isotonic Protocols-Neil Osborne and Jonathan Cook

PART VII IMPLEMENTING THE FUNCTIONAL

667

PARADIGM

28. Weight Training for Back Stability Chris Norris

688

William H. Kirkaldy-Willis

29. Advanced Stabilization Training for

Elderly-Craig Liebenson

712

30. Nutritional Considerations for Inflammation and Pain-David R. Seaman

728

31. A Cognitive Behavioral Therapy Program for Spinal Pain-Steven J. Linton PART VI PRACTICAL ApPLICATION

741 BY

REGION

Appendix 37A Physical Activity Readiness Questionnaire

751

753 776

91 4

38. Role of Non-Operative Spinal Specialist in Managing the Spine Patient-Joel Press, John and Robert Watkins

915

39. From Guidelines to Practice: What is the Practitioner's Role?-Alan Breen

33. Managing Common Syndromes and Finding the Key Link-Karel Lewit

898

J. Triano, Craig Liebenson,

32. An Integrated Approach to Regional Disorders-Craig Liebenson

889

37. The Role and Safety of Activity in the

Performance Enhancement Micheal Clark

887

36. The Patient and the Doctor

INDEX

947

933

PART

Overview CHAPTER 1

Active Care: Its Place in the Management of Spinal Disorders

Craig Liebenson CHAPTER 2

The Role of Muscles, Joints, and the Nervous System in Painful Conditions of the Spine


Quality Assurance: The Scope of the Spine Problem and Modern Attempts to Manage It


Putting the Biopsychosocial Model Into Practice

Craig Liebenson

Editor's Note

A new patient-centered model is being applied to spine disorders. Rather than focusing m erely on pathology and symptoms, t h e emp h asis is on recov ery, reactivation, and self-management. Passive care approaches u tilizing medication, modali ties, and man ipulation are being replaced with an active self care paradigm. This first section of the book lays out the added value to patients of a reactivation approach . The overwhelming evidence i n support of this new direction i s reviewed along with the rea sons why a traditional biomedical way of th inking is far from ideal for a multi factorial problem such as spine pain . This section concludes with a discussion of why, when , and how to integrate the basic steps of this broad n ew biopsychosocial model in to every day clinical practice.


Active Care: Its Place in the Management of Spinal Disorders

Craig Liebenson

Introduction

Learning Objectives

The Functional Paradigm in Diagnosis and Therapy

After reading this chapter you should be able to

The Diagnostic Dilemma in Back Pain The Rationale for Active Care The Deconditioning Syndrome Functional and Cognitive Behavioral Aspects

understand: •

•

The Clinical Examination of Function and Perfor mance

•

Correlation Between Specific Performance Deficits and Low Back Pain Cognitive-Behavioral Components The Negative Effects of Immobilization and Bed Rest

•

A Patient-Centered Approach Evidence of Active Care's Effectiveness: Does It Exist? Prevention Acute Phase (First 4-6 Weeks) Subacute Phase Reactivation and Exercise (From 4-12 Weeks) Chronic Phase Reactivation and Exercise (After

12 Weeks) Active Care and the Neck

•

The c urrent state of k nowledge for t h e diagnosis and classification o f pati en ts with low back dis orders The relationship between functional distur bances and spi nal disorders The relationship between psychosoci al factors, s uc h as fear-avoidance behavior, and decondi tioning syndrome The distinction between specific dysfunctions s uc h as losses of strength or mobi l i t y and general dysfunctions such as walking or sitting i ntoler a nces The evidence for t h e effectiveness of active care in t h e treatmen t of spinal disorders "One of the most tragic events of our time is that

we know more than ever before about the pains and sufferings less able to respond to them. "

Henri Nouwen

3

4

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Part One: Overview

Introduction

Activity has been shown to be effective for preventing or treating many of t h e most common c hronic ail m ents i n our soc i ety today (77). In particular, active care or pati ent reactivation plays a decisive role in the modern management of disorders of t h e cardiovascu lar and locomotor systems (75,94,95,161,183,189,195, 200,201). From simple, uncomplicated reactivation advice to com prehensive, m ultidiscipl i nary rehabili tation, t h e goal is to restore function. The functional goal i s a n essen t i al h i nge for guiding c l i n ic i an s i n t h e dec ision-making process. Biomec hanical, neuro physiological, psychosocial, and biochem i cal ratio nales exi s t for t h e benefi ts of active care. However, t h e m ost i m portant justification for making reacti vat ion a pri mary focus of care is that patients i n pain tend to accept the adage " l et pain be your guide," with the result bei ng they decondition as a result of t heir pain. Persistent pain rei n forces negative attitudes about the relationship of activity and pain as the patient takes on the "sick" role (147). Diagnostic tests that focus on pathoanatomy are frequently ordered to find the "cause" of the pain. Unfortunately, t h ese tests have h igh false-posi tive rates for coincidental structural findings, such as degenerative joint disease or herni ated discs, and thus reinforce the pati ents self-image as having a "bad" back or needing to "learn to live with it" (14,15,23,96,99,111,239,255,271). The result is fur ther activity avoidance and deconditioni ng. Unfortu nately, excessive i m mo bilization interferes with t h e h ealing, copi ng, a n d recovery process. Thus, h ealth care professionals are being urged by each successive international guideline on spinal disorders to first per form a diagnostic triage to rule out "red flags" of rare but serious disease, and t h en to reassure pati ents of the benign nature of thei r back pain and the safety and value of gradually resum ing activities (2,25,38,94, 148,217). The evidence i n favor of reactivation for spin e patients i s strong. Reactivation advice t o resum e near normal activi ties is both safe and effective for acute low back pain (LBP) patients (148) . Similarly, early activation has been found to be effective for neck pain after a whiplash i njury (18,166,213). Deconditioning normally accompanies acute LBP and i ts preven tion has been s hown to reduce recurrence rates (82,83, 234). Active therapies involving such diverse exercise methods as cognitive-behavioral, stabi li zation, and strengthening have demonstrated t heir effect iveness for subacute and chronic LBP (11,58-60,83,94,95,113, 128,150,190). Therefore, at each phase of the acute to chronic pain continuu m , patien t reactivation has been shown to play a fundam en tal role.

The Functional Paradigm in Diagnosis and Therapy

L B P is a subjective symptom t hat correlates poorly with objective findi ngs. Less than 1 5% of LBP patients can be given a precise pathoanatomical diagnosis. These patients are labeled with general terms such as sprain/strai n , "non-specific," or idiopat hic LBP. Fortu nately, most low back conditions have a favorable nat ural history. However, pat ients who don't recover rapidly with "tincture of t i me" can become frustrated. The physician shares in this fTustration with the result being t hat tests are ordered that have low predictive value and thus are u n l i kely to make a di fference in patient care. I n fact, the reservoir of coi nciden tal struc tural pathology ( false-positive results) in pat ients is so h igh that performi ng advanced i m aging i njud iciously has the unwanted side effect of i ncreasing anxiety and propagating an u ndesirable, interventionist cascade in pursuit of the cause of the pain ( 1 77 ,269,27 5 ) . The problem of back pain then i s not what t o d o for the majority o f patients who have a satisfactory outcome,

l

but rather what to do for the disproportionately costly m inority who do not. Because the goal of care is to restore function, are we able to identi fy the impairments and cognitive-behavio �a 1 factors that linlit performance . . so that treatment deCISIons can be gUIded by a valid, logical reason ing process?

The Diagnostic Dilemma in Back Pain The Problem

Optimal cli nical m a n agem ent depends on accurate d i agnosis. Unfortunately, only a m i nori ty of back pain pati ents can be given a clear diagnosis of their pain generator or relevan t pathoanatomy (2). The conundrum o f t h e LBP problem is that whereas most patients do well despite this diagnostic failure, the vast majority of the costs arise [yom the mi nority of t hose who become chronically disabled (80). Current "state-of-the-art" guidelines suggest per forming a diagnostic triage to classify patients with low back problems i n to t h ree distinct groups. First, caused by "red flags" of serious disease, e.g., tumor, infection, fracture, or serious m edical disease «2%); second, caused by nerve root compression (

6

DURATION OF ABSENCE FROM WORK (months) Figure 3.3 Compensation costs ror back i nj u ry i n groups

w i t h di rferent dura t ions or absence from work. Quebec, 1 98 1 . From Spit zer WO, Le Blanc FE, D u puis M, et a l . Scien tific approach to t h e assessment and management or activity-related spi nal d i sorders: A m onograph for c l i n icians. Report of the Quebec Task Force on Spinal D isor ders. Spine 1 987; 1 2(suppl 7 ) : SI-S59.

Natural History for Spinal Disorders Other Than Low Back Pain

Sciatica is a common condition that typically lasts longer than LBP (44,156). The presence of leg pain has been shown prospectively to at least double the risk of a back problem becoming persistant (odds ratio, 2.55; 95% confidence interval, 1.3 to 5.1) (151). The lifetime prevalence for it is estimated to be between 14% and 40% (111,145,156). Surgery for sciatica is estimated to be necessary in between 1.3% and 3.1% of the population (41,86,156). In contrast, spinal stenosis does not have such a favorable prognosis (44). Approx imately 15% of patients improve, 15% worsen, whereas the remainder remain fairly stable. Neck and s houlder problems occur in nearly as many individuals as LBP, with a lifetime prevalence between 50% and 71% of the population (34,111). The I-year prevalence rate is nearly 14.6 % in Saskatchewan (34) and 17.9% in England (38); 48% of neck pain episodes persist at 1 year (70). According to Makela (105), the chronic problem is frequent, affect ing 9.5% of males and 13.5% of females. Like LBP, neck pain is generally persistant, with only one-third experiencing a complete resolution of symptoms (35). Headache has a high point prevalence of 16% to 22% and a lifetime prevalence of more than 90% (111). Whiplash injuries are common, but their duration is controversial (103). Many authors (59,102,117) esti mate it to last approximately 2 to 3 months, w hereas others have concluded that 20% to 70% of the time pain persists at least 6 months later (13,14).

Two quite distinct sets of risk factors can be identified in those with LBP. First are those that predict who will have acute LBP. Some of these may actually be pre disposing or etiologic factors. Second are those [ac tors that predict which acute LBP patients will have chronic pain. These can be thought of as perpetuating or prognostic factors. Prevention efforts are depen dent on accurate risk factor identification. Because the cost of such preventive approaches is usually a consideration, groups at high risk are those who would be the likely targets. Prevention of acuteLBP is considered primary prevention, whereas prevention of c hronic LBP in those already having acute LBP is termed secondary prevention. Primary prevention efforts have been notably unsuccessful, whereas sec ondary prevention has become the focus of most recent guidelines statements (2,39,76,129,130). The best studies of risk factors are those that are prospective, because they can infer more accurately causation. In contrast, cross-sectional or retrospec tive studies only reveal associations and often conse quences rather t han causes. There is a rapidly growing body of literature on risk factors for LBP, but very few for sciatica or neck pain.

Risk Factors Associated with the Onset of Acute LBP

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Can factors related to the development or spi nal pain and disabil i ty be ident ified so that better primary pre ventive efforts can be designed, investigated, and pro moted?

Risk factors for the development o[ acute LBP have been divided into two general groups-individual and external. If risk factors for acute LBP can be identified, perhaps workers can be better-matched to occupa tions so as to reduce the incidence of costly, disabling episodes. Additionally, primary prevention measures depend on accurate identification of risk factors to be efficacious. Individual The primary individual risk factors for

onset of back pain are related to age, socio-economic class, education level, long-term activity levels, and self-rated health. Gender, genetics, congenital anom alies, degenerative conditions, muscle strength, and cardiovascular fitness have all been found to be unre lated to LBP onset. Smoking has been shown to be

Chapter Three: Quality Assurance

related, but the causal link is tenuous. Evidence that fitness and higher levels of physical activity over the long-term are correlated with reduced incidences of back pain exists, but so does short-term evidence to the contrary. Strength has not been shown to be related toLBP, but endurance has, although it is weak and controversial. Flexibility's relationship to LBP is controversial. Height and weight are often referred to as related to LBP episodes, but there is evidence to support and to reject the hypothesis. Table 3.3 sum marizes the main categories of individual risk factors for acute onset LBP. Psychosocial Fear-avoidance beliefs have been found

to be prospectively related to the development of pain and dysfunction (96). The relative risk (RR) is 2.0 to 2.5 (96). The RR is the ratio of incidence rates for a condition in two distinct populations. Thus, individ uals with substantial fear-avoidance beliefs are two times to 2.S-limes more likely to have LBP than those without such beliefs. High levels of distress have been shown to strongly predict that future episodes of LBP would be more likely to become chronic (151). In an asymptomatic group of 23-year-olds evaluated and then re-evaluated again 10 years later, psychological distress increased risk more than 2-fold for future LBP (odds ratio, 2.52; 95% confidence interval) (123). Depression was found to be an inde pendent predictor of onset of an episode of neck or low back trouble (24). Self-rated health is a potent predictor of new episodes of LBP (37,78). The relative risk in men is 1.5, whereas in women it is 2.2 (37). Below-average self-rated health has also been shown to predict that future episodes of LBP would be more likely to become chronic ( 151).

Table 3.3 Major Categories of Individual Risk Factors for Acute Onset LBP • •

•

•

•

Psychosocial (self-rated health) Physical-functional (activity level-short-term and long-term, flexibility/motion characteristics, strength, endurance, balance, cardiovascular fit ness, lifting capacity) Physical-structural (congenital anomalies, degenerative conditions) Work-related (some are also psychosocial or physical)-job satisfaction, low social support in the workplace Socio-demographic (age, socio-economic class, education level, gender, genetics, smoking, anthropometric-height, weight)

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57

Phys ical-Functional

Activity level The relationship between overall fitness

and LBP episodes is one of the more interesting potential risk factor. Cady showed in a large prospec tive study of 1652 fire fighters that higher levels of physical fitness were preventive ofLBP episodes (22). Leino found that men wHh lower baseline levels of physical activity were at greater risk [or LBP 10 years later (87). No such elevated risk was round in women. Harreby found that inactive teenagers were more likely to have LBP 25 years later than physically active ones (67). Similarly, Videman found that compared to elite athletes, matched controls had more LBP (163). In contrast, Croft (37) found that activity levels were not correlated with subsequent LBP in the short-term, over a 1-year period, except for the [ollowing: •

•

Regular sports activity in women is related to LBP: RR, 1.3 Do-it-yourself activities in men are related to LBP: RR, 1.8.

In a related study, low levels of physical activity level were found to be strongly correlated with future development of chronic LBP in asymptomatic indi viduals ( 151). Cardiovascular fitness Cardiovascular fitness has not been shown to be related to f-uture onset of LBP (3,125,154). Muscle strength and endurance There is some evidence that poor isometric endurance of lhe back muscles is predictive o[ LBP episodes (8,101). However, this has been disputed by Takala (148). Stevenson et al reported that the electromyographic median [Tequency shift (increased rate of decline) during sustained contractions of the erector spinae and quadriceps strength and endurance each pre dicted future LBP in workers involved in manual material handling (144). Lifting capacity Isomelric lifting capacily was nol shown to be correlated by Ballie (Baltie 1989) bUl was correlated by Chaffin, Liles, and Takala. (27,91, 148). Balance Poor balance was correlaled wilh fulure LBP by Takala (148). Flexibility Reduced flexibility was shown lo be related by Battie (4). However, increased range of motion (ROM) has been idenlified as a risk faclor in women and decreased ROM in men, according lo Biering-Sorensen and Takala (8, 148). A novel dimen sion of ROM is the patienl's nalural speed or accele ration during testing. Decreased thoracic acceleration

58

Part One: Overview

during ROM testing was shown to be positively asso ciated with future LBP (144). Physical-structural (congenital anomalies, degenera tive conditions) Spinal x-rays have been used for many years to screen workers in high-risk occupa tions for potential risk of disabling back conditions without finding any predictive value (146). The Occu pational Health Guidelines (OHG) (12,15,168) fyom England summarize current scientific opinion on this subject quite succinctly, "It is important to address a very commonly held misconception about the rela tionship between various structural findings and spinal disorders. Historically, the public and clini cians have assumed that congenital abnormalities such as tropism or spina bifida, degenerative changes in discs or facets, spondylolisthesis, and herniated discs were all structural changes which if present would predispose a person to future LBP, sciatica, or neck pain episodes. To date the con-elation is very weak. The likelihood of an asymptomatic individual with any of these structural pathologies developing clinical problems in the future is hardly greater than [or someone without them." Work-Related: Job Satisfaction, Low Social Support in the Workplace Job salisFacliol1 There is strong evidence for low job

satisfaction as a risk factor for LBP. The magnitude of risk estimate (relative risk) is 1.7 to 3.0 (9,10,72, 120,122,127). This risk also extends to future acute episode being more likely to become chronic (151)! Social sllpporl il1 Ihe workplace There is also significant evidence that low social support in the workplace correlates with future onset of disabling LBP (72). The magnitude of risk is estimated to be 1.3 to 1.9 (10,126). Sociodemographic (Age, Socio-Economic Class, Education Level, Gender, Genetics, Smoking, Anthropometric-Height, Weight)

Il can be said that LBP is more common in those between late adolescence and the early 40s. After the age of 60, incidence rates begin to decline. New evidence suggests LBP may be more common than thought in even younger individuals (112,167).

Age

Socio-economic class Lower socio-economic class is related, for a variety of reasons, such as external [actors including heavier manual labor (167). In fact, the relationship is stronger for the duration of disability than it is for actual incidence of episodes.

like socio economic class is more related to duration of disabil ity than actual incidence rates [or LBP (167). Educalion

level Low education level

Smoking Smoking has clear effects on the anatomic

structures of the low back. Decreased blood flow and nutrition to the disc, lowered pH of the disc, demin eralization of the vertebral bodies, altered fibrinolytic activity, and increased degenerative changes have all been described. However, epidemiologic studies show there is only a very weak correlation between smoking and LBP and no correlation with sciatica (80,112). An exception is Croft's recent study, which showed that current smokers have more LBP than non-smokers or former smokers (37). Height and Weight Anthropometric measures such as

height and weight have been looked at in numerous studies reviewed by Nachemson (112). An early study of US military recruits found that those hospitalized for LBP were significantly taller and heavier than control subjects (73). Croft found that women in the shortest quintile had reduced risk (37). Kopec el al found height was correlated with LBP in men, but not women, whereas weight was not a factor for either sex (78). Deyo and Bass found that there was an increased likelihood of the heaviest individuals having LBP when compared with the lightest indi viduals (42). Shekelle found no relationship between body mass index (BMI) and back pain in 3000 adults (137). Croft found that both weight and body mass index were related to subsequent LBP in the next 12 months with borderline significance (37). They also found increased weight in women increased the risk. Women in the heaviest quintile had a relative risk of 1.8 compared to those in lowest quintile. No similar association was found for men. In this study, the risk associated with BMI was the same as for weight. External Work activities have been studied exten sively for their possible association with f-uture onset of LBP. Whole-body vibration such as in truck and automobile drivers, as well as frequent bending (flex ion) and twisting, have been shown to be related to both LBP and sciatica (164). Both repetitive work tasks (arm or neck movements) and manual handling (carrying, lifting, pushing, and pulling) have been shown to be related to future onset of LBP. According to the Occupational Health Guidelines (OHG) (168) from England summary, "There is strong evidence that physical demands of work (manual ma terials handling, lifting, bending, twisting, and whole body vibration) are a risk factor for the incidence (onset) of LBP, but overall it appears that the size of the effect is less than that of other individual, non occupational and unidentified factors." Risk Factors for Neck Conditions Static load has

been shown to be related to neck pain (i.e., heavy exposure to visual display unit work is cOlTelated with neck pain) (164). Also, somewhat weaker evidence suggests that work tasks involving forceful arm move-


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59

ments are correlated with neck pain (164). Fatigue, sleep problems, less sports activity, and high psycho somatic score in those 15 to 18 years old predicted f-uture neck and shoulder pain (7 years later) (140). Female sex, having given birth to more children, psy chological distress, previous LBP, and previous neck injury are other lisk factors for future neck pain (70). Depression has been prospectively linked to h.lture neck pain (24). There is a trend toward a greater inci dence of neck pain in women, and it peaks between the ages of 30 and 45 (34); 50% of all soft tissue neck injuries are related to automobile accidents, with a female preponderance (162). Other causes are acci dental falls (25%), sports injuries (24%), and bicycle injuries, with a male preponderance (162).

and cost-effective to substitute more aggressive treat ment for a less aggressive approach (52). Basically, because most individuals who are disabled by acute LBP have a low risk for chronic disability, it would be necessary to treat a very high percentage of all dis abled individuals to even make a small difference in the return to work outcomes. Frank explains "the number needed to treat" to make a signi ficant dif ference in outcomes declines quickJy after the first month. This is because of the [acts that : (a) the pool of individuals suffering is much smaller; and (b) these individuals' likelihood of spontaneous recovery is much smaller. According to Frank, there are three distinct stages in terms of risk of an acute episode becoming chronic (52) (Fig. 3.4):

Perpetuating Factors for Poor Recovery of LBP:

Acute-First 4 weeks : risk of chronicity is low

Prognostic Factors

Subacute-Weeks 4 to 12: risk is high "ipso facto" and the survival curve suggests aggressive treatment will be cost-effective here Chronic-After 12 weeks: recovery halts

Because many acute L B P patients recover with m i n i mal i ntervention, aggressive treatment or all acute L B P patients i n t h e hope o r reducing t h e expensive chronic problem is cost-inerficienl. H owever, can pri mary care providers iden t i ry a subgroup of acute patients at h igh risk ror chronicity so that an efficient allocati on of resources can be used to prevent chronic pain before i t i s establ ished?

_-.l

Although long-term disability affects a small percent age of patients, they consume a disproportionate portion of the overall costs. Once chronic pain and disability is established, it is very resistant to treat ment. Therefore, if it can be predicted who will be resistant to recovery, then more aggressive treatments given early on to those individuals may reduce the chronic problem. Frymoyer was one of the first to focus on identifi cation of high risk patients, "if a patient is identified early in the course of the low back pain episode to have a high risk for disability, early, aggressive reha bilitative efforts may be more successful and cost effective than permitting the patient to have a longer period of disability with its resultant economic, social and medical consequences" (45). Others have fol lowed in Frymoyer's footsteps (11,53,54,89,90,92, 93,151). To scientifically determine whom should receive more versus less aggressive care, Frank has presented the concept of the "number needed to treat" to deter mine the cutoff for when it would be more efficient

Frank warns that a risk factor for acute pain becom ing chronic is overly aggressive acute management (therapeutic or diagnostic) (52,102). Therefore, he states, "there is ample evidence that the prognosis [or m ost patients with LBP (who have only ordinary low back strain) is so good, even without any medically prescribed treatment, that only minimal investigation and treatment, together with substantial reassurance, is warranted" (53). Staging patients uncovers the patients at greatest risk for chronicity by the mere presence of continued disability after 4 weeks. Individual risk factors for acute pain becoming chronic are called "yellow flags" (Table 3.4). They are divided into those related to symptoms, examination, psychosocial, functional, and work-related factors. Most are subjective and they are predominately psy chosocial. In contrast to "red flags," which require urgent attention, further testing, and possibly s pecial ist referral, "yellow flags" only require a shift in the focus of care. These risk factors have been shown to predict future chronic pain or disability in acute LBP patients (19,30,54,69,76,92,93). Some have shown that they can predict future chronic LBP in individu als before they have an episode of acute LBP (151). It has been demonstrated that formal use of a question naire has higher sensitivity and predictive value for identifying distressed patients than simple history tak ing alone (63). In the context of disabling back pain, the individual lisk factors exist alongside health care provider, work place, and compensation risk factors (116). Williams et al showed that whereas psychosocial factors are

60

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Part One: Overview

1 00% (J)

C

CIS

80%

S .Y.

CIS � - 0

�0 :::: �

60%

01 _ CIS =

40%

a..

20%

GJ O

C U) GJ � GJ

II

III 15

o 3 to 4 weeks

12 weeks

20

25

40

35

30

45

50

Time (Weeks) Since Pain Onset

Figure 3.4 Three-phase model of low back p a i n natural history. From

Frank J W , Kerr M S , Brooker AS, et al . Disab i l i ty resu l t i ng from occupa tional low back pain . Part 2: What do we know about secondary preven t i o n ? Spine 1 996;2 J :29 1 8-2929.

Table 3.4

"Yellow Flags" Risk Factors of Chronicity

Symptoms

( 1 9,30,45,48,52,53 ,60,83, 1 09, 1 35, 1 5 1 , 1 59): • • • •

Duration of symptoms Sciatica Severe pain intensity Widespread pain

Physical Examination ( 1 9,33,66,77,84, 1 48, 1 49, 1 70): • •

•

Positive straight leg raise test Positive neurological examination (motor, sensory, reflex) Restriction in two or more spinal movements

Psychosocial Factors

significantly involved in those not returning to work, only 0 . 5% of workers disabled for 6 months had treatment that addressed these issues (173). Work place dissatisfaction is a key element in those who are disabled, yet proactive policies at the workplace to facilitate return to work are not commonly seen (10,151,116). The compensation system itself is adver sarial and this contributes to the problem (116). Perpetuating Factors for Persistant Neck Conditions

Persistent neck pain is predicted by co-morbid LBP, cycling as a regular activity, older age, and being out of work (70). Whiplash Associated Disorders classi fication II patients with neuropsychologic problems have a worse prognosis over a 3-year follow-up period ( 1 50).

( 30,43 ,45 ,66,77 ,92,93 , 1 09, 1 5 1 ) : • • • • • • •

Three or more Waddell signs of illness behavior Self-rated health as poor Fear-avoidance beliefs Anxiety Catastrophizing Self-efficacy Locus of control

Work-Related

( 25 ,26,30,33 ,66,69,72,92,93, 1 09, 1 5 1 , 1 73 ) • • • •

Involved in compensation or litigation Physically demanding job (or perception of) Job dissatisfaction Disability in the previous 12 months

Functional (92,93, 1 09) • •

Light work or activity tolerance Sleep negatively affected by pain

Evolution of Evidence-Based Healthcare ...

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C l i n ic i ans and consumers are [aced with the [Tll strating challenge of judging the veracity of orten contradictory cla i ms o[ effect iveness for a broad array or tests and trea t m e n t s for s p i n a l problem s. How can one s i ft through the widely varying empirical clai ms and vast sci entific l iterature t o detel-m i ne what i s appropriate care?

What Is Evidence- Based Healthcare? Introduction

Evidence-based health care (EB HC) is designed to evaluate the overwhelming volume of medical litera-


ture and disseminate the most valid and important findings to prac titioners. EBHC helps clinicians to determine which management approaches (diagnos tic and therapeu tic) are proven effective, proven inef fective, or lacking in sufficient evidence to draw a conclusion. Those with evidence of effectiveness are typically ranked [rom weakest to strongest based on the quality of the studies, with RCTs given the great est weight. Those neither proven nor unproven are usually called experimental and viewed skeptically if they are either expensive or potentially dangerous. Those that are proven ineffective are debunked and their use discouraged! With the advent of EBHC, clinical or practice guidelines about the efficacy of different management approaches for a wide variety of health care condi tions (e.g., breast cancer surgery, hysterectomy, hyper tension, mammography screening) have emerged. The US Institute of Medicine (IOM) (5 1) defines such guidelines as "Systematically developed statements to assist practitioner and patient decisions about appro priate health care [or specific clinical circumstances." Low back pain guidelines have been released through out the world including Canada, the United S tates, England, Sweden, New Zealand, the Netherlands, and Denmark. According to Chapman-Smith "the primary goal of guidelines is to improve standards of care by bringing the most up-to-date knowledge to clinical practice in a form that is easy to use" (28). Wiesel recommends that we distinguish guidelines from standards of care by virtue of their being based on expert consensus opinion rather than scientifically strong evidence ( 172). A major goal of guidelines players is to produce diagnostic and therapeutic protocols or algorithms with scientifically sound decision points. Eddy esti mates that if strong evidence is present for all decision points that diagnosis and treatment will be appropri ately directed [or more than 95% of the patients of the specific disease entity (47). According to Wiesel, when only consensus-based decision points are available for algorithms, this figure decreases to 60% (172). He states that to use a guideline to influence management decisions, ". . . the physician must be prepared to modify the recommended care as the specific clini cal setting dictates." This echoes the sentiments of Sacket t (131) the pioneer of EBH C who says, "clini cal expertise should be informed but not replaced by evidence." The Agency for Health Care Policy and Research's (AHCPR's) introduc tion states the following reasons for LBP guidelines (2):

•

•

High prevalence of low back problems in society High cost of the low back problem to society

Widespread variation in practice habits

Growing body of scientific literature demon strating evidence of ineffectiveness [or certain commonly used assessment and treatment approaches

Cherkin et al surveyed a large group of medical phy sicians (nearly 1200 respondents) regarding their beliefs about the efficacy of different treatments [or LBP (29). The only treatment that a majority recom mended was physical therapy. Less than half of the physicians believed that spinal manipulation was effective, yet substantial minorities believed bed rest and narcotic analgesics were effective. The s tudy highlighted that physicians lack a consensus on what is appropriate care for LBP. Furthermore, the only treatment they generally agreed is effective is consid ered by most systematic reviews and guidelines to be merely supportive (physical therapy). Most alarming is that a substantial minority believed in treatments such as bed rest and narcotic analgesics, which have been demonstra ted to lack effectiveness, whereas missing fyom nearly half of the respondent's list was spinal manipulation-one of the only treatments that actually has evidence of effectiveness for LBP.

Summary of Major New Conclusions From Successive Guidelines

Many international teams of research methodologists, clinical scientists, and health care providers have been brought together to review the available "best evi dence" for the management of low back and neck pain. Their consensus opinions do NOT represent a new standard of care, but the guidelines that have emerged have proposed a revolutionary new para digm for managing spinal disorders. What follows is a brief summary o[ the most important of these inter national guidelines.

1 987: Quebec Task Force (1 42) •

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• •

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Increasing evidence that much of the care for low back problems is either inappropriate or suboptimal o

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Specific diagnosis of acute LBP is possible in only 20% of cases Management different [or acute stage than for later stage: 7 weeks was the cutoff U tility of diagnostic imaging limited and not recommended routinely Iatrogenic effects of bed rest prescription discussed

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Part One: Overview

Early return of patient to normal activity recommended even if pain is present

•

Specific recommendations regarding manual therapy are given o

1 994: Agency for Health Care Policy

o

and Research (AHCPR) (2) •

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•

Perform diagnostic triage with special emphasis on finding "red flags" requiring urgent attention Recommended very strict criteria be applied to the decision to have surgery Recommended spinal manipulation as one of the few primary treatment options for acute LBP requiring additional symptomatic relief

o

o

•

•

For patients with acute pain of more than 2 to 3 days For acute recurrences or flare-ups o f chronic pain As part of an overall approach to manage chronic LBP As part of the approach for nerve root problems

The GP and DC are recommended as the portals to the system The emergency room should not be a portal except for trauma patients because such physicians lack the necessary evaluation skills

1 994: Clinical Standards Advisory Group (CSAG) (3 1 ) •

•

Recommended biopsychosocial assessment at 6 weeks Described appropriate versus inappropriate use of medication

1 995: Quebec Whiplash Associated Disorders (WAD) Guidelines 1 995 (1 43) •

•

Recommended classification system based on signs and symptoms Recommended early, active intervention (including manipulation)

1 995, 1 999: Royal College of General Practitioners (RCGP) ( 1 29, 1 30) •

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•

Recommended consideration of refelTal to specialists i[ primary care failed (4-6 weeks) Recommended early identification of psychosocial risk factors of chronicity

2002: Dutch Royal Physical Therapy Association and the Dutch Society of General Practitioners (1 33) • •

Recommended exercises for those not returning to normal activities within 6 weeks

Guidelines for WAD grades 1 and 2 Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery.

1 997: New Zealand (76) •

•

Described the psychosocial aspects of pain and how to uncover them [Tom history Provided a screening questionnaire for identi fying psychosocial "yellow flags" risk [actors of chronicity

2003: Dutch Physiotherapy Guidelines for Low Back Pain (5) •

•

1 999: Denmark - Danish Institute for Health Technology Assessment (39) •

•

First guidelines to include a health technology assessment that considered ethical issues, health care organization, and economics Recommended advice that emphasizes overcoming fear-avoidance behavior and that hurt does not equal harm, rather than traditional "back school" with more "careful" advice

Distinguished between impairments, disabilities, and participation based on the International Classification of Human Functioning, Disability, and Health (171). Behavioral therapy incorporating a time contingent rather than pain-contingent approach is recommended

2005: European Guidelines for the Management of Acute Nonspecific Low Back Pain in Primary Care - Preliminary Draft (50)

For Prevention of LBP •

There is limited evidence for prevention of LBP


•

•

The most exists for physical activity/exercise and biopsychosocial eduction The emphasis should be on prevention of the consequences of LBP-care-seeking, disability, recurrence, work loss

For Acute LBP •

•

Be aware of psychosocial factors, and review them in detail if there is no improvement Mul tidisciplinary treatment programs in occupational settings may be an option for workers with subacute low back pain and sick leave for more than 4 to 8 weeks

•

•

•

•

Prognostic factors including psychosocial distress, depressive mood, severity of pain and functional impact, prior history, and patient expectations should be assessed Cognitive-behavioral, exercise, educational, and multidisciplinary (bio-psycho-social) treatmen t can be recommended; also, back schools and short courses of manipulative therapy Physical therapy modalities cannot be recommended Acupuncture, injections, intradiscal electrothermal therapy, spinal cord stimulation, radiofrequency lesioning of the dorsal root ganglion cannot be recommended Surgery cannot be recommended unless after 2 years of all other conservative measures have failed or are unavailable

Implementation of New Evidence .

: .

.. .

.

. . .

Guideli nes have been publi shed throughollt the world, which sum marize the scientinc evidence and m u l ti d isci plinary expert consensus opinion about recen t changes in cl i n i cal managemen t . Has publication of guidelines actually i mproved the qual i ty of heal th care [or spinal disorders and if not, why not?

Although guidelines have nourished, practitioner's implementation of the suggested changes in practice has not occurred. The Fourth International Forum on Low Back Pain Research in Primary Care, in Israel in March 2000, recognized this problem and was thus entitled, "Implementation and Dissemination: Getting

63

Research into Practice" (16). The focus of this meet ing was on hO\", to change behavior of health care providers ( R CPs). Rainville showed that physician recommendations for activity restrictions and dis ability with chronic LBP patients vary widely and are fTequently more restrictive than is recommended in consensus guidelines (124). The Paris Task Force ( J ) identified the following obstacles to clinical util ization of the guidelines: •

•

For Chronic LBP •

--

•

•

•

The primary care physicians seeing back patients are a diverse group difficult to reach with educational outreach Guidelines do not differentiate types of activity or define activity yet they all recommend it No discussion of tools that evaluate Functional capacity Guidelines take a very aggressive tone with physicians in that they recommend physicians to alter behavior and admit failure No description of the clinical profile of the necessary specialists is given

Revolutionary changes in cardiac care incorporating early activation were readily incorporated into prac tice because heart patients are seen by a single spe ciality of physicians. In contrast, less than one-third of all patients with LBP seek care and when they do, they go to a diverse array of RCPs. In fact, the largest grou p are GPs who have widely differing views about proper management of LBP (29) and in whom education measures will not be nearly so simple as in cardiology ( 1 24). According to Rossignol education must be part of a new system of care that is easy for the doctor (128). Most valuable is better explanations to patients and their participation 111 decision-making. Guidel ines by themselves are not likely to improve quality; however , it is not because they are unnecessary. Rather, they are necessary just not suFficient. The Danish guidelines emphasize for the first time that it is not just provider behavior that must change, but the entire health care milleau must undergo a transformation (39). Specifically, they endorse better interdisciplinary cooperation between different R CPs. They recommend that management methods should not differ substantially from RCP to R CP. To encour age these paradigm shifts common postgraduate courses should be offered [or different R CPs involved in managing LBP. Goldberg has "benchmarked" a novel approach to using education to reduce surgery rates (61). By tar geting areas with high surgery rates and using a non coercive approach, a 9% reduction in surgery rates was achieved. Surgeon study groups were used to

64

Part One: Overview

review the scientific evidence on surgical indications and the implications of different rates of surgery. Surgeons and t heir patients participated in out comes research to assess indications and outcomes of surgery. A 6-month follow-up was included and the surgeons received a report showing how they com pared with their peers. Conferences for primary care providers were offered that explained what evidence based spi ne care entailed. Emphasis on minimal bed rest, early return to normal activity, avoidance of early imaging, and appropriate criteria for surgical referral were all discussed. A local general physician pre sented essential facets of this new approach i n w hat is called "academic detailing." Videodiscs were used for patient education of surgical candidates. An over view of the results of surgery were presented along with interviews of bot h satisfied and dissatisfied patients after a variety of surgical and non-surgical procedures. Lastly, a hospital intervention led by a health care economist was directed at administrative personnel and emphasized cost-effectiveness issues. A recent Australian study revealed that significant changes in physician behavior could be achieved by a mass media campaign (18). Physicians appeared motivated partially by their more informed patients. They were found to give more reactivation advice and less prescribed bed rest than t heir peers who were not in a province exposed to t he mass media campaign. Similar education, in Scotland, aimed directly at the consumer has shown promise (134). Frank and Loissel have s h ow n t hat in a highly complex and costly occupational setting, it may not malleI' as much what different strategies are offered as it docs t hat the worksite is involved. Explicit in volvement of the workplace includes workplace visits by rehabilitation specialists to negotiate individual ized job modifications (52,99,100). Shared decision-making is another proposed solu tion to mee ting t he needs of t h e various players involved in back pai n . In s hared decision-making, the patien t is involved with the clinician i n c hoosing among different options. This empowers patients by giving them some control over the decision-making process. By involving t he patient in t his process, it has the potential to increase their satisfaction with the process regardless of outcome. Studies involving patients wi th heart disease have show n that through shared decision-making patients become both more kn owledgeable and confident (88,110). Such a n approac h was recen tly used with prospective surgi cal candidates for lum bar disc surgery. It was show n that a n in teractive video program facilitated patient decision-making about t heir treatment (121). Von Korff proposed that HCPs should negotiate with their patients their respective roles, responsibili-

ties, and expectations (166). The HCP is the trainer and the patient is the active participant. A key to the success of such active participation is mutually agreed on goals. Back problems with their recurrent natural histories are more like asthma or diabetes. Like such chronic illnesses, treatment is not likely to be suc cessful without a self-care component (166).

Is EBHC actually better than traditional care? E B H C may be based on t h e "best evidence," but is i t

itself evidence-based ? A recent Austral i a n tri a l com pared evidence based care to t rad i t ional care ( l 08 ) . Patients were assessed at base l i ne , 3 months, 6 months, and 12 months. X-ray u t i l i zation was 7% i n the experi mental group compared to 30% in trad i t ional care group . Bed rest was recommended only 2% of t he t i me i n t h e evidence-based group versus 40% i n the tradi t ional group. T h e trad i tional care group recom mended o p iates 25% of t h e t im e . At J 2 m o n t h s , 7 1 % of the evidence-based patients were ful l y recovered, compared to 56% of t h e tradi t i onal care group. Most i m pressively, qual i ty was achieved at a reduced cost. The tradit ional care cos ted 7 1 % more than the evidence-based care.

Limitations of Evidence- Based Healthcare

Although guidelines have been a boon to clinicians and consumers alike, t hey are far from perfect. What if any are the specific limitations of low back pain guidelines? While they recommend the goal of increasing activity tolerance, t here is very little in the guidelines about h ow to improve patient's activity tolerance (1)! There is insufficient evidence t hat t hey i mprove the quality or reduce t he cost of care. In fact, in physical medicine there is often a scarcity of high-quality evidence. I n such an instance, there is a danger of giving too much weig ht to the evi dence and underestimating h ow little is actually known (152). The Quebec Task Force acknowledged that an accurate diagnosis of LBP is possible less than 20% of the time (142). However, merely because it is difficult to diagnose subtypes ofLBP does not mean they don't exist. Laboeuf-Yde has described how non-specific LBP is most likely made up of several specific sub types that are not yet identified (8 1,82). As discussed in chapter 1, new classification schemes are emerging that show that improved care results from identifica tion of the subclassifications of "non-specific" LBP patients (46,49,56).


I mproving the Quality of Evidence-Based Guidelines

For EBHC to be the "benchmark" for quality in health care, a rigorous ongoing process called total quality improvement is needed. Of course, quality must be achieved at a reasonable cost. Frymoyer defined value as the ratio of quality to cost (58). Success depends on flexibility, ongoing review, and participation of all the "players." From the patient's perspective, effective guidelines must be clear, specific, and unambiguous (161). According to the I nstitute of Medicine (51) and U.K. National Health Service (114), good guidelines should adhere to certain criteria: •

Define their target disorder

•

Adhere to scientifically rigorous standards

•

Be user-fTiendly

•

Lend themselves to audit processes

•

Include distribution plans

•

I nclude implementation plans

•

I nclude regular, future reviews

Important outcomes to measure to determine the usefulness of guidelines include (161): a) Patient-centered outcomes such as pain reduc tion, [unction, return to work, and satisfaction b) Health care utilization costs c) Cost of developing, implementing, and updating guidelines To stay abreast of new knowledge groups, the Cochrane Collaboration provides updates of new evi dence (32). Periodic updates of guidelines are neces sary. No established criteria for guideline revision exists. Shekelle suggests guidelines should be revised when ( 138): •

Significant changes occur in the scientific literature

•

New methods emerge

•

New outcomes are deemed appropriate

•

There is a change in the availability of health care resources

On reviewing 17 different guidelines published by A HCPR between 1990 and 1996, Sheklle et al esti mated that half of the guidelines were outdated after 5.8 years ( 139). The authors suggest that guidelines should be evaluated [or validity every 3 years.

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65

The Institute for Musculoskeletal Research and Clinical Implementation (IMRCI) developed an audit for use in England to help HCPs provide the highest possible quality care in the first 6 weeks of a low back episode (17) (see Chapter 39). The audit offers evi dence-based recommendations on specific aspects of care. The audit may guide care or can be used retro spectively to see where changes could be made to opti mize future care. Action steps, supportive evidence, and chart review are all described in detail. Another British group has formed to help GPs learn how to identify appropriate decision points for refen-ing to specialists (115). Guidelines are considered by many HCPs as merely a current trend. Such thinking is prejudiced by those who hold to u ntested belief systems (113,153). It is the challenge of those who believe in an unproven approach to secure funding for the necessary research to demonstrate the validity of the methods. However, lack of evidence of effectiveness is NOT the same thing as evidence of i neffectiveness. I n fact, certain en-oneous conclusions can be reached if it is assumed that all patients are alike. Researchers may prefer homogenous populations o[ individuals, but clini cians know that each patient is unique.

• CONCLUSION LBP is an epidemic problem i n which certai n advances are known but not generally used. The nat ural history is not as brief as has been believed, with most patients suffering prolonged symptoms and activity intolerances after acute episodes. Although it is not clear why most i ndividuals have acute LBP, we now know that acute pain becomes chronic primar ily as a result of psychosocial factors. The focus in care has traditionally taken two con trasting paths. One path is typified by limiting care for acute and subacute patients (medication and rest). The other path involves maximizing care for chronic patients (i.e., diagnostic imaging and surgery). The evidence points us i n a differe nt direction. Namely, that secondary preventive efforts should tar get i ndividuals at "high risk" for chronic pain while they are i n the subacute phase. This management does not necessitate aggressive imaging or surgery on these patients, but rather orients care toward restoring function a nd addressing psychosocial problems such as fear-avoidence beliefs and distress/ depression. How to improve implementation of this new evi dence is a major question. Unlike cardiovascular problems in which only one specialty dominates care, patients with spine problems are seen by myr iad HCPs. To get all the "players on the same side of

66

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Part One: Overview

lhe baW-patients, HCPs, insurers, government, and employers-is a major challenge for those interested in solving this epidemic problem.

Audit Process

Self-Check of the Chapter's Learning Objectives •

What is t h e l i ke l i hood of your patient h aving achieved a satisfactory recover at 3 weeks and 7 weeks?

•

What are examples of speci fic "yellow flag" risk factors of c h ro n icity?

•

What new i n formation have t h e various i nternational low back pain management guide l ines given you regardi ng patient care?

•

Are you aware of commonly used assessm e n t and treatmen t approaches that are not recommended by the various guidelines? -For i n s tance, x-rays for acute LBP w i t hout "red flags"

•

Are you aware o f assessment and treatment approaches that you were not previously u s i n g or referri ng for t h a t are recom mended by t h e various gui de l ines? -For i nstance, man ip u l ation for acute LBP without "red flags"

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82. Laboeuf-Yde C, Lauritsen J M , Lauritzen T. Why has t he search for causes of low back pain largely been nonconclusive? Spine 1 99 7 ; 2 2 : 877-88 1 .

6 7 . H a rreby M , H esselsoe G , Kjer J, Neergaard K. Low back pain and physical exercise in leisure-ti m e i n 3 8 year old m e n and wome n : A 25 year prospective cohort study of 640 school c h ildre n . Eur Spine J 1 997;6: 1 8 1 - 1 86 . 6 8 . H ashemi L, Webster BS, Clancy E A , Voli n n E . Length of d isab i l ity a n d cost o f workers' compensa t ion low back pain claims. J Occ u p Environ Med 1 998;40:2 6 1 -2 6 9 . 69. H azard RG, H a u g h L D , R e i d S, Preble J B , MacDon ald L. Early prediction of c h roni c d i sab i l i ty aher occ u pational low back i nj ury. Spine 1 996;2 1 :945-95 1 . 70. H i l l J , Lewis M , Papageorgiou AC, D ziedzic K, Cro ft P. Predi c t i n g persistent neck pai n . A I -year follow up o f a popu lation cohort. Spine 2004;29: 1 648-1 654. 7 1 . H i l l man M, Wright A, Raujarat nam G, et a l . Preva lence of low back pain in the comm u n i ty: I m p l ica t ions fOI- service provision in BradFord, U K. J Epidemi l ol Com m un Health 1 996;50: 347-3 5 2 . 7 2 . H oogendoorn W E , van Poppel M N M , Bongers P M , Koes BW, Bouter L M . Systematic review of psy chosocial factors at work and private l i fe as risk Fac tors for back pai n . Spi ne 2000;25( 1 6 ) : 2 1 1 4-2 1 25 . 7 3 . H rubec A , Nasbbold BS Jf. Epidemiology of l u m bar disc lesions in the m i l i tary in World War II. Am J Epidem i ol 1 9 7 5 ; 1 02:366-376. 74. I ndahl A, H aldorsen EH, H o l m S, Rei keras 0, H ursi n H. Five-year Follow-up study of a controlled c l i nical trial using l ight mobi l i zation and a n i n for mat ive approach to low back pai n . Spine 1 99 8 ; 2 3 : 262 5-2630. 75. J acob T, Baras M, Zeev A, Epstein L . A longi tudinal, com m u n i ty-based study of low back pain outcomes. Spine 2004;29: 1 8 1 0- 1 8 1 7. 76. Kendall NAS, L i nton SJ, M a i n C J . Guide to assess i n g psychological yel low flags in acute low back pai n : Risk factors for long-term disabi lity and work loss. Wel l i ngton, New Zealand: Accident Rehab i l i ta tion & Compensation I nsurance Corporation of New Zealand and t he National Health Comm ittee, 1 99 7 . 77. Klenerman L, Slade P , Stanley I , et a l . T h e predic tion of c h ron i c i ty in patients w i t h an acute attack of low back pain in a general practice setting. Spine 1 995;20:4 78--484.

8 3 . Lancourt J , Ketteljut M . Predicting return to work for lower back pain patients receiving worker's compensati o n . Spine 1 992 ; 1 7 : 629-640. 84. Lani er DC, Stockton P. C l in ical predictors of out come of actue episodes of low-back pai n . J Fam Pract 1 98 8 ; 27:483-489. 85. Larequi-Lauber T, Vader JP, B u rnand B, et a l . Appropriateness of i ndications for surgery of lum bar disc hernia and spinal stenosis. Spine 1 997;22( 2 ) :203-209. 86. Lawrence JS. Rheumatism in popul ations. London: Heinemann, 1 97 7 . 8 7 . L e i n o P . Does lesiure t i me physical activity prevent low back d isorders? A prospective study of metal i ndustry employees. Spine 1 993; 1 8 :863-87 1 . 88. Liao L , et a l . Impact of an i n teractive video on deci sion making of patients with ischem ic heart disease. J Gen Intern Med 1 996; 1 1 : 373-376. 89. Liebenson C , Yeomans S. Identification of the patient at risk For persistent or recurrent low back trouble. I n : Yeomans S, ed. The c l in ical appl ication of outcomes assessment. Stamford, CT: Appleton & Lange, 1 999. 90. L iebenson CS, Yeomans SG. Yellow Flags: Early ide n t i fication of risk factors of chro n i c i ty in acute patients. J Rehabil Outcomes Meas 2000;4( 2 ) :3 1 -40. 9 1 . Liles D H , Deivanayagam S, Ayoub M M , Mahajan P. A job severity i ndex for the evaluation and control of l i fting i njury. H u m Factors 1 984;26:683-693. 9 2 . L inton SJ, Hallden K. Risk factors and the natural course of acute and recun-ent m usculoskeletal pain : Developing a sCI-een i ng i nstnlment. I n : Jensen TS, Turner JA, Wiesen feld-Hall in Z, eds. Proceedi ngs of the 8th World Congress on Pai n , Progress i n Pai n Research a n d Management, vol 8. e d . Seattle: IASP Press, 1 997. 9 3 . L inton SJ, Hallden BH. Can we screen for problem atic back pain? A scree n i ng questionnaire for pre d i c t i ng outcome i n acute and subacute back pain . C l i n J P a i n 1 998; 1 4: 1 -7 . 9 4 . L i n ton SJ. Psychological r i s k factors for n e c k and back pain. I n : Nachemson A, Jonsson E, eds. Swedi s h SBU report. Evidence-based treatment for back pai n . Stockhol m/Phi l adelphia, Swedish Coun c i l on Technology Assessment in Heal th Care ( S B U)/Lippi ncotl ( Engl ish translation ) , 2000:75. 9 5 . L i n ton SJ. A review of psychological risk factors in back and neck pai n . Spine 2000;9: 1 1 48-1 1 56 .


96. L i n ton SJ, Buer N , Vlaeyen J, H e l l s i ng AL. Are fear avoidance beliefs related to a new episode of back pain? A prospective study. Psychol Health 2000; 1 4; 1 05 1 - 1 059. 97. L i n ton SJ . Cognitive-behavioral therapy in t h e pre ven t ion of m usculoskeletal pai n : Desc'rip t i o n of a progra m . In: Li nton SL, ed. New avenues for the prevention of chronic musculoskeletal pain and dis ability. Amsterdam : E lsevier, 2002. 98. Lloyd DCEF, Troup JDG. Recurre n t back pain and its prediction. J Soc Occup M ed 1 983;33 :66-74. 99. Loisel P, Abenhaim L , Durand P, et al. A popu la tion-based, randomi zed c l i nical trial on back pain management. Spine 1 99 7 ; 2 2 : 2 9 1 1 -29 1 8 . 1 00. Loisel P, Gosse l i n L, D u rand P, Lemaire J, Poit ras S, Abenhaim L. Im plementation of a parti c ipatory ergonomics program in the rehab i l i tation of work ers sufferi ng fTom subacute back pain . Appl Ergon 200 1 ; 3 2 ( 1 ) : 5 3-60. 1 0 1 . Luoto S, Heliovaara M, H urri H , AJaranta H . Static back endurance and the risk o f low-back pain . C l i n Biomech 1 995 ; 1 0:323-324. 1 02 . Mahmoud MA, et a l . C l i n ical management and the duration of disab i l i ty for work-related low back paLl. J Occup Environ Med 2000;42 : 1 1 78- 1 1 87 . 1 03 . Maimaris C , Barnes M R , Allen M J . 'Wh i p l ash i njuries' of the neck: A retrospective study. Injury 1 988; 1 9 : 393-396. 1 04. Malm ivaara A, Hakkinen U, Aro T, et al. The treat ment of acute low back pain-bed rest, exercises, or ordinary activity? N Engl J Med 1 99 5 ; 3 3 2 : 3 5 1 -3 5 5 . 1 05 . Makela M , Heliovaara M , Sievers K, Impivaara 0, Knekt P, Araomaa A. Prevalence, determi nants, and consequences of chronic neck pain in F i n l and. A m J EpidemioI 1 99 1 ; 1 34 : 1 3 5 6- 1 367. 1 06 . Marhold C, L i nton SJ, M e l i n L . Cog n i tive-behav ioral return-to-work program: Effects on p a i n patients w i t h a history of l ong-term versus short term sick leave. Pain 200 1 ;9 1 : 1 5 5- 1 63 . 107. Mason V. The prevalence of back p a i n in Great Bri t a i n . Office of Population C Censuses and Surverys, Social Survey D ivision ( now Office of National Statistics). London: Her M ajesty's Sta tionery O ffice, 1 994: 1 -2 . 1 08. McGui rk B , King W, Govind J, Lowry J, Bogduk N . Safety, efficacy, and cost-effectiveness o f evidence based guidelines for the management of acute low back pain in primary care. Spine 200 1 ;26:2 6 1 5-2 6 2 2 . 1 09. McIntosh G, Frank J , Hogg-Johnson S, Bombardier C, Hall H. Prognostic factors for time receivi ng workers' compensation benefits i n a cohort of patients with low back pai n . Spine 2000 ; 2 5 : 1 47- 1 57 . 1 1 0 . Morgan M W , Deber H A , Llewellyn-Thomas H , et a1. A randomized trial of the ischem ic heart disease shared decision maki ng program: An evaluation of a decision aid (abstract). J Gen I ntern Med 1 997; 1 2 (Suppl ) : 6 2 . I l l . Nachemson A, Waddell G, Norl u n d AI. Epidemiol

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Assessment i n H e a l t h Care ( S B U )/Lippi ncott ( Eng l ish translation), 2000b. 1 1 2 . Nachemson A, Vingard E. Influences o f individual factors and smoking o n neck and low back pai n . I n : Nachemson A, Jonsson E , eds. Swedish SBU report. Evidence-based treatment for back pain . Stock holm/P h i l adelp h i a , Swedish Council on Technology Assessment i n Health Care (SBU )/Lippincott ( E ng l ish translation), 2000c . 1 1 3 . Nachemson A, Jonsson E, eds. Swedish S B U report. Evidence-based treatment for back pain . Stockholm/P h i l adelp h i a , Swedish Cou n c i l o n Technology Assessment i n H e a l t h Care ( SB U )/ Lippi ncott ( E nglish translation), 2 000. 1 1 4 . Nati o n a l Health Service Executive. E ffective Health Care: Implement i n g C l in ical G u i de l ines, N Report N o . 8 : Can guideli nes be used t o i mp rove c l i n ical practice? 1 994: 1 - 1 2 , Leeds. 1 1 5 . National Insti t u te for C l i n i ca l Excellence. ReferTaI Advice: A guide to appropriate referral from general to speci a li st services London, December 2 00 1 . www . n ice.nhs.uk. 1 1 6. Nicholas M K . Reducing disab i l i ty in i njured work ers: The importance of coll a borative managemen t . I n : L i n ton S L , e d . New avenues for t h e prevention of chronic musculoskeletal pain and disabil i ty. Amsterdam: Elsevier, 2002. 1 1 7 . Olsson I, B unketorp 0 , Carlsson G, et a l . An i n depth study of neck i njuries i n rear end collisions. IRCOBI 1 990:269-280. 1 1 8. Papegeorgi u AC, Croft PR, Ferry S, et a1 . Est i mating the prevalence of low back p a i n i n the general popu lation: Evidence from the South M anchester back pain survey. Spine 1 995;20: 1 889- 1 894. 1 1 9 . Papegeorgiu AC, Croft P R, Thomas E , et al. I n flu ence of previous p a i n experience on the episode i ncidence of low back p a i n : Results fTom the South Manchester back pain survey. Pai n 1 996;66: 1 8 1 - 1 8 5 . 1 20 . Papegeorgiu AC, Macfarlane GJ, Thomas E , et a! . Psychosoci a l factors i n the workplace: Do they pre d i c t new episodes of l ow back pai n ? Evidence fTom t he Sou t h M anchester back pain survey. Spine 1 997 ; 2 2 : 1 1 3 7-1 1 42 . 1 2 1 . Phelan EA, Deyo RA , Cherkin D C , e t a l . H e l p i ng patients decide about back surgery: A randomi zed trial of an i n teractive v i deo program . Spine 200 1 ; 2 6 ( 2 ) :206-2 1 2 . 1 22 . P incus T, V laeyen JWS, Kendall NAS, Von Korff M R, KAlauokalani DA, Rei s S. Cog n i t ive-behavioral t herapy and psychosoci a l factors in low back pai n . Spine 2002 ; 2 7 : E 1 33-E 1 38 . 1 23 . Power C , Frank J , Hertzman C , Shierhout G , Li L. Predictors of low back p a i n onset i n a prospect i ve British study. Am J Public Health 200 1 ;9 1 : 1 67 1- 1 67 8 . 1 24 . Rainvil l e J , Carlson N , Polati n P, Gatchel R, I ndahl A. Explora t i o n of physician's recom mendations for activities i n chronic low back pai n . Spine 2000 ; 2 5 ( 1 7):22 1 0-2 2 2 0 . 1 2 5 . Ready AE. Boreskie SL, L a w S A , Russell R . Fi tness and l i festyle parameters fail t o predict back injuries i n n u rses. Can J Appl Physiol 1 993; 1 8( 1 ) : 80-90. 1 26 . R i i h i maki H , V iikari-J u n tura E, Moeta G, Kuha J , Videman T , Tola S. Incidence o f sciatic pain among

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men in mac h i ne opera t i ng, dynamic physical work, and sedentary work: A 3-year follow-up . Spine 1 994; 1 9( 2 ) : 1 38- 1 42 . 1 27 . Rossignol M , Lortie M , Ledoux E . Comparison o f spinal health i nd icators i n pred i c t ing s p inal status in a I -year longitudinal study. Spine 1 99 3 ; 1 8( 1 ) :54-60. 1 28 . Rossignol M. Coord i nation of Primary H ea l t h Care [or Back Pain . Spine 2000 ; 2 5 : 2 5 1 -2 5 9 . 1 29. Royal College o f General Practi t ioners ( RCGP ) . The development and i mp lementation of c l inical guide lines. Report of t h e C l i nical Guidelines Worki n g Group. London, Royal College of General Pract i t ioners, 1 99 5 : 1 -30. 1 30 . Royal College of General Pract i ti oners ( RCG P ) . C l i n i cal Guidelines for t h e M anagement of Acute Low Back Pai n . London, Royal College of General Prac t i t ioners (www.rcgp.org . u k ) , 1 999. 1 3 1 . Sackett D L , Rosenberg WMC, M u i r Gray JA, Haynes BA, Richardson W. Evidence-based medicine: What i t i s and w h a t i t isn't. Br Med J 1 996;3 1 2 :7 1 -7 2 . 1 32 . SCB . U nderso k n i ngar a v levnadsforhalleanden, U L F [ National h ousehold surveys] . Stockholm, 1 996 . 1 33 . Schol ten-Peeters G G M, Bekkering G E , Verhagen AP, et al. C l in ical Practice Guideli n e for the Physio therapy of Pat i e n ts W i th W h i p l ash-Associated Dis orders. Spine 2002 ;2 7 : 4 1 2-4 2 2 . 1 34 . Scotland's Work Backs Partnershi p . Working Backs Scotland 2000, www.workingbacksscotland.com . 1 35 . Sel i m AJ, X i n hua SR, Graeme F, et a l . The i mpor tance of radiating leg p a i n in assessi ng heal th out comes among patients with low back pain . Spine 1 99 8 : 2 3 :470-474. 1 36 . Shaw WS, Feuerstein M , H uang G D . Secondary pre ven tion in the workplace. In: L i nton SL, ed. New avenues for t h e prevention of c hron i c musculoskele tal pain and disab i l i ty. Amsterda m : E l sevier, 2 002. 1 37 . Shekelle PG, Markovich M , Loui e R . An epidemio logic study of episodes of back pain care. Spi ne 1 995;20: 1 668-1 6 7 3 . 1 38 . Shekelle PG, Eccles M P , G r i mshaw H M , Woolf S H . When should gu idel i nes b e updated? B r M e d J 200 1 ; 3 2 3 : 1 55-1 5 7 . 1 39. Shekelle PG, et al. Val i d i ty of the Agency f o r Health Care Pol icy and Research c l i n i cal prac t i ce guide l i nes: How quickly do guidel i nes become outdated? JAMA 200 1 ;2 8 6 : 1 46 1 - 1 47 1 . 1 40. Si ivola S M , Levoska S, Latvala K, Horkio E , Van haranta H , Kei nanen-Ki ukaanni e m i S. Predictive factors for neck and shoulder pain : A longitudinal study i n young adults. Spine 2004; 2 9 : 1 662- 1 669. 1 4 1 . Skovron M L , Szpalski M, Nord i n M, et al. Sociocul tural factors and back pain: A population-based study in Belgi a n adults. Spine 1 994; 1 9 : 1 2 9- 1 37 . 1 42 . Spi tzer WO, L e B lanc FE, D u p u i s M , et a l . Scient ific approach t o the assessment and management of act ivi ty-related spinal disorders: A monograph for c l i n icians. Report of the Quebec Task Force on Spi nal D i sorders. Spine 1 987; 1 2 (suppl 7 ) : S l -S59. 1 43 . Spi tzer WO, Skovron M L, Salmi LIR, et a l . Scien t i fic monograph of the Quebec Task Force on W h i plash-Associated D i sorders: Redefin i ng "Whi plash" and i t s m anagement. Spine I 995;20(Supp) : S 1 -S73 .

1 44. Stevenson J M , Weber CL, S m i t h JT, Dumas GA, Albert WJ . A longitudi nal study of the development of low back pain in an i n dustrial population. Spine 200 1 ; 2 6 : 1 370- 1 3 7 7 . 1 45 . Svenssson H O , Andersson G BJ. A retrospective study of low back pain i n 38 to 64 year old women: Frequency and occurrence and i m pact on medical services. Spine; 1 988; 1 3 : 548-55 2 . 1 46 . Symmons D P M , van Hemert A M , Vandenbrouke JP, Valkenburg H A . A longitudinal study o[ back pai n and radiological changes i n the l u m bar spines of m iddle-aged women.!!. Radiographic findings. Annals of the Rheumat i c D i seases 1 99 1 ;50: 1 62-1 66. 1 47 . Szpalski M, Nord i n M, Skovron ML, et al. H ealth care u t i li zation [or low back pain i n Belg i u m . I n flu ence of sociocultural factors and heal th bel iefs. Spine 1 995;20:43 1 -442. 1 48 . Takala EP, V i kari-J u n tura E . Do fu nctional tests predict low back pai n . Spine 2000 ; 2 5 ( 1 6) : 2 1 26-2 1 32 . 1 49. Taylor H , Curran N M . The Nupri n Pai n Report. New York: Loui s Harris and Associates, 1 98 5 : 1 -2 3 3 . 1 50. Tenenbaum A , Rivano-Fischer M , Tjell C , Edblom M , Sunnerhagen KS. The Quebec Classification and a new Swedish classification for w h i plash-associ ated d isorders in relation to l i fe satisfaction in patients at h i gh risk of c h ronic funct ional i m pair ment and d isab i l i ty. J Rehabil Med 2002 ;34: 1 1 4-1 1 8. 1 5 1 . Thomas E , S i l man AJ, Croft PR, Papageorgiou AC, Jayson M IV, M adarlane GJ. Predicting who devel ops chronic low back p a i n in primary care: a prospect i ve study. B M J 1 999;3 1 8 : 1 662- 1 667. 1 52 . Tonel l i MR. I n defense o[ expert opinion. Acade m ic Medic i ne 1 999:74; 1 1 87- 1 1 92 . 1 53 . Trial and error. Econom ist 1 998;93. 1 54. Troup J D G , Foreman TK, Baxter CE, Brown D . The percep t i on of back pai n and the role o[ psychophys ical tests of hf-ting capaci ty. Spine 1 987; 1 2 :645-657. 1 5 5 . Truchon M, F i l l ion L . B i opsycbosocial determ i nants of chro n i c d isabi l i ty and low-back pain: A review. J Occu p Rehab 2000; 1 0: 1 1 7- 1 42 . 1 56 . Tuback F, Leclerc A. Natural h i story of sciatica, pre sented at the annual meeting of the American Col lege of Rheumatology, Phi ladel p h i a , 2000. 1 57 . UK General Household Surveys. London: Office o[ National Statistics. 1 58 . Urs i ny J, et al. Manag i ng the costs of care for low back pain : Experience w i t h i n a large health care deli very system, presented at the annual meeting of the American Coll ege of Rheumatology, P h i ladel p h i a , 2000. 1 59. van den Hoogen H J M , Koes BW, Deville W, van E ij k J T M , Bouter L M . The prognosi s of low back pain in general practice. Spine 1 997;22: 1 5 1 5- 1 52 1 . 1 60. van den H oogen H J M , Koes BW, van Eijk JTM , Bouter L M , Deville W. On tbe course of low back pain in general practice: A I -year follow-up study. Ann Rheum Dis 1 998;57: 1 3- 1 9. 1 6 1 . Van Tulder W E , Croft PR, van Splun teren P, et al. D issem inati ng and i m plemen t i ng the results of back pain research in primary care. Spi ne 2002 ; 2 7 : E 1 2 1 -E I 27 .


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on neck and low back pai n . I n : Nachemson A, Jons son E, eds. Swedish SBU report . Evidence-based treatment for back pai n . Stockholm/Philadelphia, Swed ish Coun c i l on Technology Assessment i n Health Care ( S B U )/L i p p i ncott ( Engl ish translati on ) , 2000. 1 65 . Von Korff M, Deyo RA, Cherk i n D, Barlow W. Back pain i n prim ary care: Outcomes at 1 year. Spine 1 993; 1 8 : 855-862. 1 66 . Von Korff M . Collaberative care. Ann I ntern Med 1 997; 1 2 7 : 1 87- 1 95 . 1 67 . Waddell G . The Back Pain Revolution, 2 n d ed. Edinburgh: Churc h i l l Livi ngstone, 2004. 1 68 . Waddell G, Burton AK. Occupational health guide l i nes for t he management of low back pain at

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Putting the Biopsychosocial Model into Practice

Craig Liebenson -

Introduction The Biopsychosocial Model Overemphasis on a Structural Diagnosis

Learning Objectives

After reading this chapter you should be able to: •

Overemphasis on Bed Rest Overuse of Surgery

•

Abnormal Illness Behavior Diagnostic Triage to Rehabilitation-The Benchmark

•

Reassurance/Diagnostic Triage Reactivation Advice Relief of Pain Re-Evaluation of Structural, Functional, and Psychosocial Contributors to Continued Pain or Disability Reconditioning Referral Practitioner Audit

•

Understand the limitations of a biomedical approach in managing spine pain patients Understand the importance of functional reacti vation as a guiding principle in spine patient care Understand the i mportance or psychosocial fac tors such as fear-avoi dance behavior in a patient when t here is failure to achieve a satisfactory outcome Understand the "decision points" of care when i m plementing the biopsychosocial model i nto clinical practice

"Let fear, then be a kind of pain or disturbance resulting from imagination of impending danger, either destructive or painful." Aristotle

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Chapter Four: Putting the Biopsychosocial Model into Practice

73

Introduction

Individuals with persistent activity limi ting low back pain (L BP) generally assume that structural factors play a decisive role in their pain and disability. H ow ever, it is now acknowledged that most structural pathologies are present in asymptomatic individuals in nearly equal degree as they are in those who are symptomatic. This fact combined with the generally unsatisfactory results of tradi tional care for LBP has led to the critical evaluation of the biomedical model (49,66,97). Accord i ng to the International Association for the Study of Pai n ( lASP), pai n is not simply the result of structural i nj ury or pathology but is "an unpleasant sensory and emotional experience associ ated with actual or potential tissue damage . . . " (63 ). Pain has its origi n i n peripheral activation from physical sources; however, it is also modulated in the dorsal horn, and by descend i ng influences largely of psychologic origin (57). Concurrent evaluation of both the sources of pain and the psycho-physical per ceptions that lead one to fear and t hus avoid activity should be addressed so that reactivation can occur (39,53,94). Thus, musculoskeletal pain patients in general and LBP patients in particular require an approach that addresses the physical (biological) and psychosocial dimensions of their problem. This modern approach is called biopsychosocial ( BPS) in that the total patient is our subject. Rather than focusing on structural causes and cures, this new paradigm emphasizes the goal of maintaining or restoring function. Such an approach is of value regardless of the pathoanatomic diagnosis. This BPS approach is the main subject of not only this chapter but also the entire book that follows. The Biopsychosocial Model

Less t han 20% of back pai n is caused by structural fac tors. Does t h is mean that most pai n is psychogenic?

Pain has been interpreted since the time of Descartes as signaling tissue damage ( Fig. 4. 1 ). The biomedical model of finding the structural cause and then treating it or "fixing" it to elicit a cure is based on this rather narrow view of pain. It is now acknowledged that a structural cause for pain does not usually exist and that a structural cure is not often successful. The Cartesian model leads one to assume if cure is not brought about, then t he problem must be psychogenic. The dualism inherent in the early Renaissance notion of pain suggests that pain is either in the mind or body, but not both ! According to the new lASP definition of

Figure 4.1 The Cartesian model or periphcral activat ion

of pain pathways. From Descal-tc's L'Hol11l11c (Paris 1 644).

pain, i t is associated with both a disagreeable physical sensation and an emotional experience (58,59). Thus, i t is sensorial (nociceptive) and affective (emotional) and should not be defined dichotomously as either physical or psychological . The biopsychosocial model views pain as involving ascending nociceptive input from the periphery ( Car tesian model), descending modu lation that inhibits or faci l itates nociception ( Gate Control Theory of Melzack and Wall ) , and central processes with neuro logical, affective, and cognitive dimensions ( Figs. 4.24.4) (57). Therefore, the perception of pain is heavily i nfluenced both by nociception and by one's attitudes, beliefs, and soci al environment ( Fig. 4.5). Even though most patients begin improving from back pain episodes quickly, both the recurrence rate and dissatisfaction with medical care is high. Addi tionally, the m inority in whom persistant chronic dis abling pain develops account for by far the greatest percent of costs (85%). Therefore, the traditional bio medical model should be re-evaluated in light of its failure to successfully address the low back problem. In patients who do not recover, the l i m i tations of the biomedical approach are even more evident. fn an attempt to find the structural cause o f LB P, overly sensitive tests are ordered, with high false-posit ive rates. The patient either is told nothing is wrong and labelled psychogenic or is told about the pathology and to rest, take medici nes, and learn to live with it. If they can't tolerate it anymore, then they are i n formed that t hey should have surgery. The incidence rate, cost of chron icity and disabil ity, general dissatisfaction, and high reCUlTence rate add up to a problem of epidemic proportions. Waddell

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Part One: Overview

Inhibitory Large Fiber

Substantia Gelatinosa

Glands

A

TCel1

Cognitive Control

Descending I nhibitory Control

Large Fibers

I n put from Periphery Small Fibers B

Gate Control System

Figure 4.2 The gate control theory o f pain . (A) Ascendi n g pathways from small and large diameter fibers to the dorsal horn of the spinal cord and to h i gher centers. From Suchdev P K . Pathophysiology of pain. In: Warfield CA, Fausett J H, ed. Manual of Pain M anagement, 2 nd ed. P h i ladelphia: Lippincott Williams & Wilkins, 2002 . (B) The excitatory (white circle) and i n h i bitory (black circle) links [Tom the substantia gelati nosa (SG) to the transmission (T) celis, as well as descending i n h ibitory control from brainstem systems. The roun d knob at the end of the i n h ibitory l i n k i mplies t hat i ts act ions may be presynaptic, postsynaptic, or bot h . All connections are exci tatory, except the i n hi b i tory l i n k from SG to T cell. From Bon i ca JJ, Loeser J D . History of pai n concepts and t herapies. In: Loeser JD, ed. Boni ca's Managemen t of Pai n , 3rd ed. Philadelphia: LippincoLL Williams & W i lkins, 2 00 1 ( modified from Melzack R, Wall PD. The challenge or pai n . New York: Basi c Books, 1983.)

( 97) in his Volvo award-w i n n i ng paper stated, "Con ventional med ical treatment for l ow-back pain has failed, and the role of medicine i n the present epi demic must be critically examined." The low back epidemic is caused by a number of factors. The rea sons for this fai l u re are presented in Table 4.1.

Overemphasis on a Structural Di agnosis

Many doctors overuse diagnostic imaging as part of the initial evaluation of a LBP patient. This is per formed for two mistaken reasons. One is the belief that serious diseases (i.e., tumors, i nfections) can be missed

Chapter Four: Putting the Biopsychosocial Model into Practice

Central Sulcus

�(

75

Postcentral Gyrus (Somatosensory cortex)

�

Cortex

--

Social Environment

TO ASSOciation Cortex Illness Behavior

Thalamus

Psychologic Distress

Spinothala micTract

�

Spinoreticular Tract

Spino mesen-/ cephalic Tract Spinal cord

Nociceptor in Muscle

Figure 4.5 The biopsychosocial model. Reproduced with

Figure 4.3 Ascending nociceptive pathways. From

permission from Waddell G. The Back Pain Revolution. Edinburgh: Churchill Livingstone, 1998.

Mense S. Si mons DG. M uscle Pain: Understanding Its Nature, Diagnosis, and Treatmen t . Baltimore: Lippincott Williams & Wilkins, 2001.

From H ypothalamus

To Thalamus

+ �

En kephalinergic Neuron

--------... I nhibitory Synapse

PAG

--<J Excitatory Synapse

+ ROSTRAL

EAA/NT?

+

.....

MEDULLA

+

+

+

+

NE

5-HT

SP?

SPINAL CORD

�

Nociceptive I nput

Figure 4.4 Descending antinociceptive modulation. From M e nse S. Simons

DG. M uscle Pain: Understanding Its Nature, D iagnosis, and Treatment. Bal timore: Lippincott, Williams & Wilkins, 200 1 ( redrawn from Basbarum AI, Fields HL. Endogenous pain control system: brainstem spinal pathways and endorphin circuitry. Ann Rev Neurosci 1 984;7:309-338.).

76 -- Part One: Overvie\N

Medical Reasons for the Low Back Disab i l i ty Epidemic

Table 4.1

A) Overemphasis on a structural diagnosis B) Overprescription of bed rest C) Overuse of surgery

by a thorough history and physical examination. Sec ond, the belief that structural pathologies (e.g., herni ated discs, arthritis) that can only be identified with imaging are strongly correlated with symptoms. H istory and examination are more than 99% sen sitive for identifying "red flags" of serious d isease ( 2 1 ,56,97, 9 8 ) .

N o "Red Flags" o f Tumor, Infection, or Fracture Were Missed as a Result of Not Routinely Imaging Acute Patients •

Long-term follow-up of 437 patients revealed no serious di sorders were missed as a result of not performi ng routine i magi ng on acute pat ients

•

A "red n ag" checklist mostly fmm histOl-y alone was used

•

1 .4% of patients did have serious condi tions such as crush fracture, kidney carcinoma, and prostate carcinoma, but they were suspected on i n it i a l evaluation a n d referred for addi ti onal tests

Unfortu nately, even when using advanced i magi ng techni ques such as myelography, CAT scans, or mag netic resonance i magi ng, the same posit ive findings are also present i n 28% to 50% of asymptomatic indi viduals (4,9,38,43 , 74, 1 04). Similarly, in the neck, the false-positive rate for imaging has been reported to be as high as 75% in the asymptomatic population ( 5 , 81). Thus, imaging tests have high sensitivi ty ( few false-negatives) but low specificity (high false-posi tive rate) for identifying symptomatic disc problems. Furthermore, the presence of structural pathology i n an asymptomatic i ndivi dual does not predict a greater l i kelihood of future problems (6, 1 6) ! Boren stein et al performed MRI on 67 asymptomatic peo ple; 31% has abnormality of d isc or spinal canal (6). The MRI findings were not predictive of future LBP. Individuals with longest duration of LBP were not those with the greatest anatomical abnormali ties. Carragee et al studied discograms and reported that a painful disc injection did not predict LBP on follow up at 4 years ( 1 6). Though d iscograms have high sen sitivity for i dentifying tears in asymptomatic patients, it was the psychometric profiles that were found to strongly predict future L B P and work loss. Even when the diagnosis of disc herniation is rele vant , such pathology has a tendency to resolve with out surgical i n tervention. B ush et al ( 1 3 ) reported, "A h igh proportion of i ntervertebral disc herniations have the potential to resolve spontaneously. Even if patients have marked reduction of straight leg rais i ng, positive neurologic signs, and a substantial inter vertebral disc herniation (as opposed to a bulge), there is poten tial for making a natural recovery, not

McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, effi cacy and cost-errectiveness of evidence-based guidelines fOl

Disc Findings in Normal Subjects

the management or acu t e l ow back pain in primary care. Spine

2001;26:2615-2622

The false-posi tive rate for i dentifying clinically sig nificant herniated d iscs or degenerative conditions with imaging (e.g., x-ray, MRI) is so h igh as to make the tests clinically i nappropriate as screen i ng proce dures ( Fig. 4.6). The problem is that many individu als who have pain unrelated to the structural findings will be mislabeled and potentially receive unneces sary treatments. They may t h i n k of themselves as "sick" when in fact most of t hese changes are related more to age than to symptoms. After the discovery by Mixter and Barr that com pression of a nerve root by a herni ated disc could cause sciatica, t he belief i n the pathoanatomical basis for back and leg pain has been a fundamental dogma (1,64). Structural evidence of a l umbar disc hernia in a patient with appropriate symptoms i s presen t more than 90% o f t he t i me (4,3 8 ,74,104) .

100% 90% 80% 70% co E 60% 0 50% c .0 40% 6 weeks ( 1 2)

Baseline: 1 2 .1 5 weeks: 7.5 improved 1 2 . 1 -4 . 3 unimproved: 1 1 . 8- 1 0.6

Baseline: 2 7 . 6 5 weeks: 2 1 . 9 improved 26.2- 1 4 . 3 unimproved: 29. 1 -2 9 . 5

Modified from Table 3 of Roland M and Fairbank J. Roland-Morris D isabil i ty Questionnaire a n d Osweslry Disabilily Questionnaire. Spine 2000;25 : 3 1 1 5-3 J 24.

current job). This comparison allows the HCP to determine if the patient is capable of returning to their "normal" duty or current job versus to a more limiting PDC work level.

Several important items are derived from this evalu ation. These include: • •

• •

•

•

A score of RPC The RPC score categorizes the patient into one of the five physical demand charac teristics (PDC) work levels (sedentary to heavy) A perceived maximum lift/carry Internal reliability is checked when the scores or similar tasks are compared The RPC score is compared to normative data collected on working and disabled/unemployed males and females The physical demand characteristics level that the RPC score places the patient is then compared to a Job Demands Questionnaire (which describes the demands of their

Table 8.5

•

Work-related duties are circled so that tolerance to specific work activities can be appreciated and separated from non occupational duties. This can also be used to institute work-specific exercise protocols or work simulation in a rehabilitation setting.

The practicality and utility of the SFS is excellent because it takes only 5 to 7 minutes for the patient to complete and approximately 5 to 1 0 minutes to cal culate the score, interpret the results of maximum lift/carry, and compare it to their current work demands (Job Demands Questionnaire) and to the normative data. Though the intention or the SFS is

Other Validated Lumbar Spine Assessment Tools

Quebec Back Pain Disability Scale (QBPDS) (96,97)

Spinal Stenosis Questionnaire (SSQ) ( 1 53, 1 54)

North American Spine Society Lumbar Spine Questionnaire (NASS-LSQ) (36)

Million Visual Analogue Scale (MVAS) ( 1 1 5)

Curtin Back Screening Questionnaire (CBSQ) (65)

Waddell Disability Index (WDI) ( 1 70)

Activities Discomfort Scale (ADS) ( 1 59)

Resumption of Activities of Daily Living Scale (RADL) ( 1 8 1)

Low-Back Outcome Score (LBOS) (58)

Clinical Back Pain Questionnaire (CBPQ) (138)

J 56

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Part Three: Assessment

not to function as an OA tool, the RPC scores improve (increase) as the patient's disability decreases.

After analysis, a 5-point change was reported as clin ically important change with an internal consistency of 0 . 8 7 and test-retest reliability or 0.94. The SEM was estimated at 2 . 7 NDI points (95% confidence interval 2 . 7 x 95% ± 4. 5points) (see appendix form 3). A typical range for patient scores on the NDI are reported to be between 35% and 39% (1 47, 1 62). =

Neck Pain Neck Disability Index The Neck Disability Index (ND!)

(1 62) was designed using the ODI as a template. This instrument was initially studied using a sample of 1 7 consecutive whiplash-injured patients and showed good statistical significance (Pearson r 0.89, p $ 0.05). The alpha coefficients were calculated [yom a pool of questionnaires completed by 52 patients resulting in all items having individual alpha scores more than 0.75 and a totaJ index alpha of 0.80. Con current validity was reported with moderate correla tions when assessed in two different ways (0.60 and 0. 69-0. 70). It has been studied in individuals with work-related neck pain as well ( 1 64). More recently, Hains et al. (62) studied seven modified versions of the NDI against the original N DI and confirmed the validity of the original NDI items. The item presentation revealed a strong cor relation with internal consistency reported at 0 . 92 (Cronbach alpha). The NDI was utilized in monitoring the outcome of patien ts with whiplash-associated disorders (WAD) ( 1 65). The ND! favorably compared to other neck pain and disability self-report tools in a group or WA D patients ( 1 66, 1 67). In this study, the NDI, Neck Pain Questionnaire, and the Copenhagen Neck Functional Disability Index were compared for assess ing pain, impairment, and disability. The results of the study revealed numerous similarities i n content and format and equally good basic psychometric effi cacy. The NDI was found to be more extensively studied and, therefore, was the recommended tool for use in research settings. Vernon et a1. ( 1 63) compared WAD patients with three or more Waddell non-organic signs (NOS) ver sus those without and found that the mean scores of the NDI was over double for the high NOS group (1 7 . 6 ± 9 . 1 verses 36 ± 3 . 7). Additionally, it was found that strength was lower in the high NOS group. Stratford et al. ( 1 47) evaluated the use of the NDI when evaluating individual patients. They reported on 49 initial and 48 follow-up patients using the stan dard error of measurement (SEM) and also applied tbis to 1 5 stable patients. Three primary questions were asked: =

1 ) What is the variability for an obtained score value? 2 ) What is the minimal detectable change (MDC)? 3) What is a clinically important change?

=

What Is the Minimum Amount of Change in the NOI that Is Clinically Significant? •

1 0% or 5 points out of 50 (1 1 5, 1 29)

How to Score the NDI

Like the ODl it consists of 1 0 sections, each covering a d i fferent acti v i ty of d a i ly l iving ( [or example, driving, and s i t t i ng), and a 6-point rating scale [or each section ( from 0 to 5), which the patient uses to rate his or her abi l i ty to [un c tions. The disabil ity score is obtained by adding the scores of each o[ the sections ( maximum score 50), which is usually converted to a percentage (see append i x form 4 ) .

Other Forms The Copenhagen Neck Functional Dis

ability Scale has been found to have very good relia bility, responsiveness, validity, and practicality (90). The Cronbach alpha coefficient for internal consis tency was 0.9 for the entire scale, and the coefficients for individual items were all more than 0.88. Disabil ity scale scores correlated strongly to pain scores as well as to doctor and patient global assessments, indi cating good construct validity. Relative changes in dis ability scores demonstrated a moderately strong correlation to changes i n pain scores after treatment. Another validated form is the Neck Pain and Disabil ity Scale ( 1 79). A Whiplash-Specific Disability Measure has re cently been published ( 1 24). It was shown to have no significant floor or ceiling effects and high internal consistency (Cronbach alpha 0.96). It covers items relevant to whiplash patients that are absent in the NDI such as emotional health, social activity, and fatigue (see appendix form 4). =

Upper Extremity The Shoulder

The Croft Index This questionnaire has good con struct vaJidity in that it is able to discriminate between those with shoulder pain of severity sufficient to make them seek health care versus those who did not (35). It has also been shown to discriminate between those with disabling shoulder pain and those with no dis-

Chapter Eight: Outcome Assessment

ability ( 1 25). It has good concurrent validity because of its moderate con"elation with the SPADI instru ment (r 0.79) (57). I ts test-retest reliability is high (ICC 0.95) (57). A clinically significant change would require a change of 3 points to represent a change greater than the en"or associated with the instrument 95% of the time (57). It also has a high level of inter nal consistency (approximately 0.9 1 ) (57). However, the responsiveness of the tool is not yet assessed. =

Shoulder Pain and Disability Index The Shoulder Pain and Disability Index (SPAD!) covers the follow ing domains: pain, mobility, and self-care. Test-retest reliability of the SPADI is very good in a surgical pop ulation (ICC 0.9 1 ) and marginal in a primary care setting ( ICC 65,95% confidence interval) ( 1 32, 1 80). The internal consistency of the entire scale is very good (Cronbach alpha 0.9 1 ), with the disability scale higher than pain scale ( 1 80). Its construct valid ity has been established in a variety of ways, includ ing cOlTelating it with the S IP (74) and SF-36 (7). The SPADI's responsiveness has also been established (74). The minimum amount of change that is clini cally significant is 1 0% (57,74, 1 80). Neither the SPADI nor Croft form correlates well with ROM (r 0.24 to 0. 56) (57). Another popular questionnaire for use in this region is the Shoulder Evaluation Form (SEF). The SEF involves a ] 5-item activity of daily living ques tionnaire developed by the American Shoulder and Elbow Surgeons (6,1 3 6). The SEF was studied as a stand-alone instrument in the non-operative treat ment of rotator cuff tears (68). It is not as well-studied as the other forms described.

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157

administered questionnaire used t o measure the functional loss of upper extremity disorders (UEDs), including shoulder or elbow tendonitis or carpal tun nel syndrome (CTS) ( 1 26). This instrument was tested in two groups of patients in a prospective follow-up study using 1 08 patients with work-related UEDs and 1 65 patients with carpal tunnel syndrome (CTS). Good internal consistency (Cronbach alpha > 0.8 3), relative absence of floor effects, and excellent conver gent and discriminant validity, compared with mea sures of symptom severity and clinical findings was reported. The UEFS was more responsive in the CTS group when compared to clinical measures such as grip and pinch strength.

=

=

=

=

The Wrist The Carpal TUnl1el SyndrOlne Questionnaire The Car pal Tunnel Syndrome Questionnaire (CTSQ) is a valid, reliable, self-administered outcome tool used with patients with carpal tunnel syndrome (4). The validity was tested against the SF36 and reliability (test-retest) was tested at 1 and 3 weeks. A strong internal consistency score of 0 . 8 to 0.95 (Cronbach alpha) was reported and the responsiveness ranged between 0.94 and 1 .7 .

Hand Function Sort The Hand Function Sort (HFS) is a patient self-report of their ability to perform 62 tasks involving a broad range of physical demands, including ADLs. The HFS has demonstrated construct validity by virtue of the HFS scores corresponding to impairment when the dominant hand was involved in the disability, but not if it was the non-dominant hand ( 1 07).

What Is the M i n i m u m Amount of Change i n the U E FS that Is Clinically Significant? •

More than 1 5% (96)

How to Score the UEFS

Scoring of the questionnaire is sim ply the calculat ion o r t h e sum o f a l l responses. Not answel"ing one response i s allowed and i s i nterpolated a s t h e average or t h e ot her responses (see append i x form 5 ) .

The Upper Extremity Functional Index (UEFl) The UEFI was designed as a single, all-purpose upper extremity functional outcome to cover patients with shoulder, elbow, wrist, or hand symptoms ( 1 50). It has good test-retest reliability (0.94). The standard error of measurement is 3 .9 . When compared to the UEFS, this form was found to have similar test-retest reliability and cross-sectional validity but better lon gitudinal validity. Longitudinal validity was deter mined by comparison with independent clinician impression of patient improvement.

What Is the M i n i m u m Amount of Change i n the UEFI that Is Clinically Significant? •

Nine scale points

How To Score The UEFI

Subjects check wh ich answer best describes their a b i l i ties. There are 2 0 questions and SCOI"es range rrom 0 to 4 for each quest i o n , w i t h the h i gher the score the less the dysfu n c t i o n . The scori ng range for the ent ire questionnaire is from 0 to 80, w i t h 0 being the most

General Upper Quarter Function

Upper Extremity Function Scale The Upper Extrem ity Function Scale (UEFS) is an eight-item, self-

dysfunction and 80 the least dysfu nc t i on (see append i x form 6).

J 58

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The Lower Extremity The Hip There are a number of hip outcome tools

available for use (66, 89, 9 1 , 1 8 3, 1 84). Some are de signed with the objective of assessing pre- versus post surgical hip arthroplasty function ( 1 84). A commonly used hip-related outcome tool in the United States is the Harris Hip Score (66). Many young active patients with activity-limiting hip pain require a modified out come tool such as the Nonarthritic Hip Score (3 2). This form takes only approximately 5 minutes to com plete. Its reproducibility, internal consistency, and validity have all been demonstrated (32). This is a modification of a general arthritis form called the Western Ontario and McMaster Universities Osteo arthritis I ndex (8). The Knee

Functional Index Questionnaire (FIQ) A review of five methods of evaluating patellofemoral pain syndrome (PFPS) was conducted to investigate the psychomet ric properties of each tool (67). The five methods included the Functional I ndex Questionnaire (FIQ) (31); visual analogue scales for pain at worst, least, and usual; the Patellofemoral Function Scale (PFS) ( 1 29); a step test; and a subjective report of functional limitations. A sample of 56 patients with PFPS partic ipated in a randomized clinical trial before treatment and 1 month after treatment. The Functional Index Questionnaire compared very favorably to the other measures and was concluded to be a practical easy-to score tool with high utility for tracking the care of the knee-injured patient (67). The F IQ was shown to have modest test-retest reliability and to have very good internal consistency of 0 . 8 5 before treatment and 0 . 8 8 after treatment (Cronbach alpha) (3 1 ). The FIQ was also found to be a good discriminator for measuring clinical change.

Other Questionnaires The Noyes and Lysholm Knee scoring questionnaires are commonly used in assess ing the outcome of knee surgery in athletes (38). These questionnaires consist of activities of daily living con sistent with knee function. The Lysholm Knee Rating Scale was also used along with the SF-36 in a study of 426 patients with knee impairment who were treated conservatively (87). The outcome after physical ther apy revealed simultaneous improvements in the results obtained from both tools. The International Knee Documentation Committee Subjective Knee Form is a relatively new but psycho metrically robust outcome measure for health-related quality of life in knee patients (80). It has been shown to have very good test-retest reliability, internal con sistency, convergent and discriminative validity, and responsiveness. However, it is a slightly longer form to complete than the F IQ .

Ankle A simple-to-administer 1 2-question form, The

Ankle Joint Functional Assessment Tool (AJFAT), has been validated for assessing disability in ankle sprain patients ( 1 37). This is based on various vali dated knee outcome assessment tools (3 8,87). Ankle sprain patients' disability scores improve concur rently with impairment score improvements in bal ance ability ( 1 3 7). General Lower Quarter Function

The Functional Assessment Scale (FAS) The FAS has been developed for assessing functional levels in the elderly with osteoarthritis o[ the knee(s) (1 77). It was devised from the mobility and physical activity compo nents of the Arthritis Impact Measurement Scale ( 1 1 1 ), which has been shown to be reliable and valid ( 1 1 2). The FAS has demonstrated internal consistency by being able to discriminate between an elderly group with osteoarthritis and one without it (Cron bach coefficient alpha 0 . 8 3) ( 1 77). Arthritis su[fer ers' mean score was 1 3 . 0 (S D 2 . 68), whereas a control groups mean score was 6.4 (SD 1 . 35) out of maximum score of 2 5 . The age range for the sample was 54 to 79 years. Age was not associated with func tional score. This form could also have utility for measuring functional status in any lower-quarter patient with marked functional limitations relating to standing, walking, stair-climbing, or those requiring aids such as a cane or crutches. =

=

=

How to Score the FAS

Subjects c ircle the answer that best describes their abi l i t i es. There are five question a n d scores range [Tom 5 to 25 ( for each scale, a

=

1,b

=

2,

.

.

. [ = 6). H igher scores

i n dicate greater dysfu nction (see append i x [orm 7).

The Lower Extremity Functional Scale (LEFS) The LEFS was designed as a single all-purpose lower extremity functional outcome to cover patients with joint replacement, patellofemoral disorders, arthritis, ankle sprain, joint instability, etc. ( 1 6). It has superior sensitivity to change in lower extremity patients than a general measure such as the SF-36 ( 1 6). The 90% confidence interval, or error, ror a specific score is 6 scale points ( 1 6). Ninety percent o[ stable patients have an inherent variation of less than 9 scale points when tested on different occasions ( 1 6) . Thus, the Minimal Detectable Change or Minimal Clinically I mportant Difference is 9 scale points ( 1 6). I t is effi cient to administer and score. An initial follow-up study validated this questionnaire on patients with lower functional levels-these were patients recover ing from total hip or knee arthroplasties ( 1 49). A sec-


ond rollow-up study demonstrated the test-retest reliability, cross-sectional, and longitudinal validity of the LEFS on a more athletic population who had sustained an ankle sprain within the past 1 4 days (2). Because the LEFS was valid in highly disabled and high-performing individuals, this demonstrates both a strong "floor" and "ceiling" effect for this OA tool.

•

PSFS effect size

•

Numerical pain scale effects size

•

RDO effect size

•

=

=

--

159

1 .6 =

1.3

0.8

Impairment evaluation (ROM) effect size to 0.6

=

0.1

What I s t h e Minimum Amount o f Change i n the PSFS that Is Clinica l ly Significant? What Is the Minimum Amount of Change

•

3 scale points ( 1 78)

in the LEFS that Is Clinically Significant? •

9 scale points ( 1 6)

How to Score the PSFS

Subjects choose t hree activities that are giving them the How to Score the LEFS

Subjects check which answer best describes their abil i ties. There are 2 0 quest ions a n d scores range fTom 0 to 4 for each question, with the h igher the score the less

most trouble. They then score them on a scale of 0 to 1 0 , w i t h 0 mean i ng "unable to perform activi ty" and J 0 mea n i ng "able to perform activi ty at pre-inj ury level" (see appendix form 9 ) .

the dysfu nction. The scori ng range for the en tire ques tion naire is from 0 to 80, w i t h 0 being the most dys function and 80 the least dysfu nct ion (see appendix form 8).

Summary

A wide variety or region specific functional question naires are available that measure a patient's activity intolerances related to his or her chief symptom. Table 8 . 6 summarizes the author's recommenda tions for which rorms to choose for which regions of the body.

Patient-Specific Functional Disability Outcome Patient-Specific Functional Scale (PSFS)

The PSFS is an innovative OA tool that allows the patient to choose three activities they either are unable to perform or are having the most difficulty with as a result of their pain (2 7,1 43, 1 48 , 1 78). The PSFS has been shown to be more responsive than other outcome tools or impairment tests ( 1 22).

Table 8.6

Recommended Outcome Forms

Any region-PSFS Low back-Revised ODI, R DO or Back BO Neck-ND I or Neck BO Upper Extremity-UEFI Lower Extremity-LEFS

The PSFS was designed to be administered weekly. It is to measure progress (make ongoing clinical decisions) and outcome. It could be administered less often if slower change is expected. The MDC of three is validated per item, rather than the average of all three items. Activities mentioned by patients are all of different levels of dirficulty and averaging could mask potential improvement on one while others may change slower. As an example, if a breast cancer patient has shoul der dysfunction, number one on her PSFS might be playing volleyball (not on most functional scales!), and combing her hair and washing floors are numbers two and three. Obviously, two and three will change faster and when number one increases to nine or 1 0 on the scale, it will likely mean that she is ready for discharge. The clinician should set short-term goals around the "easier" items with an "increased ability to play volleyball to more than eight out of 1 0" as a mea surable long-term goal.

Summary

The PSFS is an excellent complement to the more well known region specific functional disability scales.

Work Status

Many reasons exist for measuring work outcomes (7 1 ,109). Five that stand out include (3): •

To assess productivity loss in clinical trials

•

To evaluate the effectiveness or health services

1 60

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Table 8.7

Psychometrics of WL-26 Scales

Scales

Number of Items

Con bach Alpha

Scaling Success'�

6 8 4 3 5

0.88 0.88 0.92 0.08 0.90

1 00% 91% 94% 92% 95%

Work scheduling Physical demands Mental demands Social demands Output demands

" Scaling success is the extent that an i tem correlates with the scale it i s hypothesized to correlate with as opposed to another scale. A success rate greater than 90% is considered successf-u l . Repri nted with permission from A m i c k B e , et a l . S p i n e 2000;25(24 ) : 3 1 5 2-3 1 60.

•

•

•

To target injury and re-injury prevention programs To evaluate the effectiveness of work reorganization projects such as ergonomic changes To improve provider-worker and provider-safety engineer interaction

The Work Loss-26

The WL-26 is an example of a generic role-specific measure. Originally, it was designed for use in occu pational illness and injury populations but has since been used in the clinical setting, especially those managing a variety of musculoskeletal disorders (Table 8 . 7). The WL-26 scales can discriminate between work ers with low or high hand-wrist symptom severity or upper extremity functioning. Also, construct valida tion is supported by emerging data on the relationship between work limitations and productivity. In general, when a worker's capacity to work is limited because of a condition, work performance is compromised. Amick et a!. described a 20-point change in work lim itations for Massachusetts workers with upper extrem ity musculoskeletal disorders as being associated with an additional 2.7 weeks of lost productivity (3).

Summary

The simplest measure by far of work status is the actual time off work. For most practitioners this may be the most practical outcome to obtain.

Patient Satisfaction Outcomes Assessment Tools

The fifth domain described by Deyo et al and Bom bardier is patient satisfaction (23,43). This is an impor-

tant domain when assessing quality assurance issues (4 1 ) . Table 8 . 8 represents a partial list of some of the patient satisfaction questionnaires available ( 1 5, 29,34). B y identifying the patient who is dissatisfied with care early on, realistic advice can be given to the patient, and frustration, disappointment, and even anger in patients who do not respond can be avoided (30). Deyo reported that most people treated for hypertension, cancer, and other serious medical dis eases are satisfied with their care. However, 20% to 25% of patients presenting with back and neck pain for medical care are dissatisfied (42).

Symptom Satisfaction

Cherkin et al. (30) asked a novel question to a sam ple of 2 1 9 patients, "If you had to spend the rest of

Table 8.8 Examples of Various Patient Satisfaction Questionnaires Test

Conditions Tested

1 . Client Experience Survey

Patient satisfaction

2. Client Satisfaction Questionnaire


3. Patient Experience Survey (PES)


4. Chiropractic Satisfaction Questionnaire (34)


5. Work APGAR ( 1 5)

Job satisfaction

6. Patient Satisfaction Subscales (29)



your life with your condition as it is right now, how would you feel about it?". He found that at 1 week one-third were satisfied; at 3 weeks one-half were satisfied; at 7 weeks two-thirds were satisfied; and at 1 year 85% were satisfied. In this sample, 82% of patients presented for their first visit of a recurrent low back pain episode in less than 3 weeks [Tom the episode's onset.

Symptom Satisfaction Is a Novel and Highly Predictive Measure of Recovery

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161

The Patient Satisfaction Subscales (PSS)

The Patient Satisfaction Subscales (PSS) was de signed for patients with lumbar spine problems (2 8 , 2 9, 7 6). The PSS consists of 1 7 items, of which 1 0 are used that reflect three distinct dimensions of care: information (3 items), caring (4 items), and effectiveness (3 items). Table 8 . 9 includes the mean, standard deviation, and Cronbach alpha for each subscale. This tool was specifically recommended to be used in outpatient settings and because of its practicality of being short ( 1 0 items) and easy to score (76).

Cherkin showed that a patient's sat isfaction with his o r her cu rrent symptom status was a s predictive of func t ional and symptomat ic recovery as self-rated healt h , sciat ica, and a h istory of frequent episodes of LBP ( 3 0 ) .

How to Score the Patient Satisfaction

T h i s can b e determ i ned with a s i ngle question-

Subscales

" If you had to spend the rest of your l i fe w i t h your

condi tion as it is right now, how would you feel about it?" o

2

Each of the t h ree subscales are scored by calculating the mean o f the i tems in each subscale. An overall total scale score is then obtained by adding the numerical

3

4

5

6

7

Delighted

8

9

10

value of the 1 0 subscale items (maximum score possible

Terrible

is 5 x 1 0 or, 50) (see appendi x form 1 0) .

Job Satisfaction

Psychological Distress

Bigos and colleagues used the work APGAR in a lon gitudinal, prospective study of 3020 aircraft employ ees to identify risk factors for reporting acute back pain at work ( 1 5). At a 4-year follow-up point, 279 subjects reported back problems. Subjects who stated they "hardly ever" enjoyed their job tasks were 2 . 5-times more likely to report a back injury (P 0.000 1 ) compared to subjects who "almost always" enjoyed their job tasks. The authors conclude that " . . . a broader approach to the multifaceted problem of back complaints in industry helps explain why past prevention efforts focusing on purely physical factors have been unsuccessful." The modified work APGAR is a seven-item tool derived initially from a family APGAR-a six-item family function questionnaire (5 5,1 40). Further mod ifications came based on findings from the retrospec tive analysis of the Boeing company work force ( 1 4), and two additional questions were added for this study (1 5), making the total number of questions to seven. A simple scoring method is based on the for mula: Patient Score / Total Possible x 1 00 % risk. Responses include "almost always," "some of the time," and "hardly ever" with points of 0, 1 and 2, respectively. A score of "0" represents no risk, whereas a maximum score of 1 4 (7 x 2 1 4) divided by the highest possible score of 1 4 equals 1 , multiplied by 100 equals 1 00%, which represents the highest risk possible. =

=

=

Different questionnaires for evaluating psychosocial aspects of illness in back pain patients have been developed (92, 1 0 1 , 1 02). Although there are numer ous condition-specific questionnaires that measure pain and disability, most do not address affective or cognitive aspects of the pain experience (see also Chapter 9). It has been shown that utilizing a ques-

Table 8.9 Using a 305-Patient Sample, the Three Subscales of the PSS, and the Associated Mean, Standard Deviation and Chronbach Alpha Are Reported Mean ± Standard Deviation

Cronbach alpha

Information

2 . 72 ± 0.92

0.75

Caring

2 .09 ± 0.67

0 . 84

Effectiveness

2.59 ± 0.76

0.7 1

Overall score

NA

0.87

PSS Subscales

Reprinted with permission from C herkin D , Deyo RA , Berg A O . Evaluation o f a physician education interven tion to i mprove primary care for low-back pain: I I . I m pact o n patients. Spine 1 99 1 ; 1 6: 1 1 73- 1 1 78. NA, not ava ilable.

1 62

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tionnaire for identifying psychosocial stress is more reliable than first impressions from a history (59). The Back Bournemouth Questionnaire The Back

Bournemouth Questionnaire (BQ) is a hybrid measur ing instrument that consists of seven scales covering pain intensity, disability in activities of daily living and social life,anxiety, depression, fear-avoidance behav ior, and locus of control (2 1 ). The back BQ has been shown to be valid, reliable,and responsive. The inter nal consistency (Cronbach alpha 0.9) and test-retest reliability (ICC 0.95) are very good (2 1 ). This is on the basis of two administrations in stable patients (n 61), indicating strong agreement between total scores in these patients. The back BQ has shown good construct validity because of its strong comparison to other outcome measures, especially the Revised aDI questionnaire (Pearson r 0. 78) (2 1 ). The back BQ is responsive to clinically significant change, as demonstrated by its high effect size. This was 1.29 for LBP, which was comparable to other established measures in the same study population such as the Revised aDI (1 .07) (2 1 ). The effect size for the neck is 1 .43 (22).

responsiveness (22). The effect size of the Neck BQ is considerably greater than [or the NDI or Copenhagen scale (22). Scoring of the Neck BQ is identical to the Back BQ (see appendix form 12).

• CONCLUSION Clin ical Utility of OA Tools

=

=

=

=

OA tools can be used to establish mutual ly agreeable goal s of care. I f the N D I reveals that neck d iscomfort is greatest with driving, then i mproving this activity intol erance can be established as a pri mary goal of care. Uti l i zi ng OA tools hel ps to rocus patients on funct ional goals such as reduction or activi ty intolerances so that symptom reduction is not the sole outcome of interest. OA tools can be used on a weekly or monthly basis to review pat ient progress towards mean ingr-ul goals. If the OD! shows a prominent sitting or walking intolerance, then progress in these fu nctional parameters can be moni tored, discussed , and problem-solved on an ongo i n g basis. Such functional , outcome-based dialogues with the patient are an i ntegral part or pat ient care. They allow cli nician and patient to discuss if the patient has

What Is the Minimum Amount of Change

reached a key "decision point" in care such that a di ffer

i n the Back BQ that Is C l i nically Significant?

ent treatment modal i ty, d iagnostic assessment, or refer

Stable subjects were found to exh i b i t changes o f between 2 . 6 a n d 4 . 5 poi n ts (or 3 . 7% to 6.4%) over time.

ral is indicated. Such discussions are often necessary to avoid patient d i ssatisfaction with care that can arise when i nappropriate expectations exist.

Thererore, change scores more than 4 . 5 ( 6 .4%) are i n d i cative of real change beyond the variab i l i ty i n change

Outcome-based dialogues offer an opportunity to

scores in stable subjects who used this scale. The mean

review m u tually agreed on goals as well as the patient's

score before treatment in LBP subjects was 50.3 ±

prognosis and expected cou rse of recovel-y. Funct ional

1 8 .8% ( 2 l ) .

outcomes a l low for a d i scussion centered on expecta tions and ach ievements ( 6 1 ).

How to Score the Back BO

OA reports are i nval uable for quant ifiably demonstrat

The ind ividual items are sum med to produce a total

i ng a patient's c l i n ical status. i m provemen t . or lack

overall score. Because the seven d im ensions each have a

t hereof. This is i m portant for med-legal report i ng.

maximum score of 1 0, it is best to express the total score

i nsurance review progress reports, or referral let ters to

or the back BO as a percentage (see appendix rorm 1 1 ) .

other health care providers. The integrity of case man agement is preser·ved by u t i l i zing rel iable. val id, and responsive outcomes to measUl-e a patient's progress

The Neck Bournemouth Questionnaire The same seven core items used in the Back BQ are used in the Neck BQ. Some minor changes were made such as replacing activities like "walking," "climbing stairs," and "gelling in/out of bed/chair" in the back BQ by activities "liFting," "reading," and "driving." The instrument demonstrated high internal consistency on 3 administrations (Cronbach alpha 0 . 87, 0.9 1 , 0.92) (2 2). The form demonstrated good reliability in test-retest administrations in stable subjects (ICC 0.65) (2 2). The treatment effect size was found to be very good ( 1 .43-1 . 67), contributing to its good =

=

over time.

All outcome, or evaluative, measures must be valid (measure what they purport to), reliable (repro ducible in stable conditions), and responsive (able to detect clinically significant change in the status of the patient). Many outcome tools, although initially considered a burden by health care providers, are surprisingly simple to administer. They enhance doctor-patient communication and improve goal setting and decision-making.


Outcome measurements are essential to unmask ineffective treatments believed to be effective. If an outcome represents a mutually agreed on goal between provider and patient, then improvement in the outcome should demonstrate if treatment is suc cessful. Regular re-evaluation with outcome mea surements is thus important so that treatment that does not improve outcomes can be re-directed. Sim ilarly, treatment that is effective but for which a provider is having difficulty justifying to a third party payer can now more easily be defended.

Audit Process Self-Check of the Chapter's Learning Objectives •

What is the m i n i m u m amount of change that i s clinically significant i n the fol lowing O M tools ODI, VAS or N RS, N DI, UEFS, LEFS, PSFS, and backJneck BQ?

•

Do you know the mean scores in specific clinical populations for the OM questionnaires that you plan to use i n your practice?

•

How can measurement of activity i n tolerances such as with the 001 help establ ish realistic goals of care for a patient?

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98. Kopec JA. Measuring functional outcomes i n per sons w i t h back pai n : A review of back-specific ques t ionnaires. Spine 2 000;2 5 : 3 1 1 0-3 1 1 4. 99. Last J M . A dictionary of epidemiology, 3rd ed. New York: Oxford U n iversity Press, 1 995. 1 00. Leclaire R , B lier F, Fortin L, Proulx R. A cross sectional study comparing the Oswestry and Roland-Morris fu nctional disability scales i n two populations o f patients with low back pain with dif ferent levels of severity. S p i ne 1 997;22 :68-7 l . 1 0 1 . Linton SJ , Hallden K . Risk factors and the natura l course of acute a n d recurrent m usculoskeletal pain : Developing a sCI-ee n i ng i nstrument. I n : Jensen TS, Turner JA, Wiesenfeld-Hall i n Z , eds. Proceedings of the 8th World Congress on P a i n , Progress in Pain Research and M anagement, Vol 8 . Seattle: IASP Press, 1 997.

1 1 6. Mooney V, M a theson L N . Objective measurement of soft tissue injury: Feas i b i l i ty study examiner's manual . Industrial Medical Council, State of Cal i fornia, 1 994. 1 1 7 . Morley S, Pal l i n V. Scaling the affective domain of pain : A study of the dimensional i ty of verbal descriptors. Pain 1 995;63 :39-49. 1 1 8 . Nelson EC, Landgraf J M , Hays RD, et a l . The COOP function charts: A system to measure patient func tion i n physicians' offices. I n : Lipkin M Jr, ed . Func tional Status M easurement in Primary Care: Frontiers of Pri mary Care. New York: Springer Verlag, 1 990:97- 1 3 l . 1 1 9. Ohlund C , Eek C , Palmblad S, Areskoug B , Nachem son A. Quantified pain drawing in subacute low back pain : Val idation i n a non-selected outpatient i ndustrial sample. Spine 1 996;2 1 : 1 02 1 - 1 03 1 .

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1 3 l . Rissanen A, Alarant H , Sain i o P, H arkonen H . Isoki netic and non-dynametric tests i n l ow back pain patients related to pain and d isab i l i ty i ndex. Spine 1 994; 1 9: 1 963- 1 967.

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Appendix SA

GLOBAL IMPRESSION OF CHANGE Since the start of my care,my overall status is: 1 . D Very Much I mproved 2. D Much Improved 3. D Minimally I mproved 4. D No Change 5. D Minimally Worse 6. D Much Worse 7. D Very Much Worse Farra J T , Young JP, LaMoureauz L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an I I -point numerical pain rating scale. Pain 200 1 ;94: 1 49-1 5 8 . Hagg 0 , Fritzell P , Nordwall A. The clinical importance o f changes i n outcome scores after treatment for chronic low back pain. Eur Spine J 2003 ; 1 2 : 1 2-20.

Name Date

______

Signature

_ _ _ _ _ _ _ _ _ _

_ _ _ _

Form 1 (48,6 1 ) Global Impression of Change.

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1 70


REVISED OSWESTRY DISABILITY QUESTIONNAIRE Name Date This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in every day life. Please answer by checking one box in each section [or the statement that best applies to you. We realize you may consider that two or more statements in any one section apply, but please just shade the spot that indicates the statement that most clearly describes your problem. _ _ _ _ _ _ _ _ _ _ _

Section 1 : Pain Intensity A. I have no pain at the moment B. The pain is very mild at the moment C. The pain is moderate at the moment D . The pain i s fairly severe a t the moment E. The pain is very severe at the moment F. The pain is the worst imaginable at the moment

Section 5: Sitting A. I can sit in any chair as long as I like B. I can only sit in my favorite chair as long as I like C. Pain prevents me silting more than one hour D. Pain prevents me [rom sitting more than 30 minutes E. Pain prevents me from silting more than 1 0 minutes F. Pain prevents me [rom sitting at all

Section 2: Personal Care (Washing, Dressing, etc.) A. I can look after myself normally without causing extra pain B. I can look after myself normally but it causes extra pain C. I t is pain[lll to look after myself and I am slow and careful D. J need some help but can manage most of my personal care E. I need help every day in most aspects of self care F. do not get dressed, wash with difficulty and stay in bed

Section 6: Standing A. I can stand as long as I want without extra pain B . I can stand as long as I want but it gives me extra pain C. Pain prevents me from standing for more than 1 hour D . Pain prevents m e from standing [or more than 30 minutes E . Pain prevents m e from standing [or more than 1 0 minutes F. Pain prevents me [Tom standing at all

Section 3: Lifting A. I can lift heavy weights without extra pain B. I can lift heavy weights but it gives me extra pain C. Pain prevents me lifting heavy weights off the noor but I can manage if they are conveniently placed, e.g., on a table D. Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned E. I can only li[t very light weights F. I cannot lift or carry anything

Section 7: Sleeping A. My sleep is never disturbed by pain B. My sleep is occasionally disturbed by pain C. Because of pain I have less than 6 hours sleep D . Because of pain I have less than 4 hours sleep E. Because of pain I have less than 2 hours sleep F. Pain prevents me from sleeping at all

Section 4: Walking A. Pain does not prevent me walking any distance B. Pain prevents me fTom walking more than 2 kilometers C. Pain prevents me [rom walking more than 1 kilometer D. Pain prevents me [Tom walking more than 500 meters E. 1 can only walk using a stick or crutches F. I am in bed most of the time

Section 8: Social Life A. My social life is normal and gives me no extra pain B. My social life is normal but increases the degree of pain C. Pain has no significant effect on my social life apart [Tom limiting my more energetic interests, e.g., sport D . Pain has restricted m y social li[e and I do not go out as often E . Pain has restricted my social life t o m y home F. I have no social life because o[ pain


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1 71

REVISED OSWESTRY DISABILITY QUESTIONNAIRE (Continued) Section 9: Traveling

Section 1 0: Employment/Homemaking

A. I can l ravel anywhere wi thout pain

A. My normal homemaking/j o b activit ies do not

B . I can lravel anywhere but it gives me extra pain C. Pai n is bad but I manage journeys more t han 2 hours D. Pain restricts m e to journeys of less than 1 hour E. Pain reslricls me to short necessary journeys less lhan 30 m i nutes F. Pain preve n ts me from travel i ng except to receive treat m e n t

cause p a in . B . M y normal homemaki ng/job activi ties i ncrease my pain , b u t I can still perform all t hat i s required of me.

C. I can perform most o f my homemaki ng/job activ i t i es, b u t pain preven ts me [Tom perform i ng more physica l ly stressful activi t ies ( e . g . , l i ft i ng, vacuuming). D. P a i n prevents m e from doing any t h i ng but l ig h t duties

E. Pain prevents me [Torn d o i ng even l ig h t d u ti es F. P a i n prevents me from performing any job or homemaki ng c hores

M i n i m u m Detectable Change (90% confidence): 1 5 points M i nimum Cli nically I m portant D i fference (90% confidence ) : 6 points

Form 2 (52) Oswesll-:, Low Back Pai n D i sab i l i ty I ndex. Form reproduced with permission from Fritz 1M, I rrgang J J . A comparison o f a modified Oswesl ry Low Back Pain D isab i l i ty Questionnaire a n d t h e Quebec Back Pain D isab i l i lY Scale. P hysical Ther 2001;8 ] : 776-788.

1 72

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ROLAND-MORRIS LOW BACK PAIN AND DISABILITY QUESTIONNAIRE When your back h urts, you may fi n d i f d i fficult to do some of t h e t h i ngs you normally do. M ark only the sen tences t ha t describe you today.

1.

0

2.

0 I c h a nge posi t i o n fTequently to try and get m y back comfortable.

3.

0 I walk more slowly t han usual because o f m y back.

4.

0 Because o f my back,

I a m n o t doing any jobs t ha t

5.

0 Because o f m y back,

I use a handrail t o get upstairs.

6.

0 Because o f my b a c k , I l i e d o w n t o rest more often .

7.

0 Because of my back , I h ave to hold on to some t h i ng to get out of an easy chair.

8.

0 Because of my back, I try to get other people to do t h i ngs for me.

9.

0 I get dressed more slowly than usual because of my back.

I s tay at horne most of t h e t i me because of m y back.

I usually do around the house.

1 0 . 0 I stand up only for short periods o f time because of m y back. I I . 0 Because of my back, I try n o t to bend or kneel down. 1 2 . 0 I find it d i ffi c u l t to get o u t of a chair because of my back. 1 3 . 0 M y back i s p a i n fu l almost all of the t i m e . 1 4 . 0 I fin d i t d i fficult to t u r n over i n b e d because of my back. 1 5 . 0 My appet i te i s not very good because of my back pain . 1 6. 0 I h ave trouble p u t t i ng o n m y socks (or stock ings) because o f p a i n i n my back. 1 7 . 0 I walk o n ly s h ort d i stances because of my back pain. 1 8 . 0 I sleep l ess well because of my back. 1 9 . 0 Because of back pain, I get dressed with help from someone else. 20. 0 I sit down for most of the day because of my back. 2 1 . 0 I avo i d heavy jobs around the house because of my back. 22. 0 Because of back pain, I am more irritable and bad tempered w i t h people than usual. 23. 0 B ecause o f my back , I go upstairs more slowly than usual . 24. 0 I stay i n bed most of t h e time because of my back. Patien t name

______

Patient signature

______

Date

Form 3 ( 1 34) Roland- Morris Low B ac k P a in and D isab i l i ty Form reprinted with permission from Roland M, Morris R . A study of the natural h i s tory of back p a i n : Part I: Development of a rel iable and sensitive measure of disabil i ty in low-back pai n . S p i ne 1 98 3 ; 8 : 1 4 1 - 1 44 .


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1 73

NECK PAIN DISABILITY INDEX QUESTIONNAIRE

PLEASE READ: This questionnaire is designed to enable us to understand

how much your neck pain has affected

your abi l i ty to manage your every day activi ties. Please answer each section by c i rc l i ng the ONE C HOICE that most applies to you . We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE THAT MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

SECTION I-Pain Intensity

SECTION 5-Headaches

A I have no pain at the moment.

A I h ave no headaches at a l l .

B T h e pai n is very mild a t t h e mome n t . C The pain is moderate at the moment.

B I have slight headaches w h i c h come i n frequent ly. C I have m oderate h eadaches w h i ch come

D The pain is fairly severe at t h e moment.

E The pain is very severe at the moment. F The pain is the worst i maginable at the

i n frequen tly. D I have moderate headaches w h i c h come frequently.

E I have severe headaches which come fTequently.

moment.

F I have headaches almost all t h e t i m e .

SECTION 2-Persol1al Care (Washing, Dressing, etc.)

SECTION 6-Concentration

A I can look after myse l f normally w i thou t caus-

A I c a n concentrate ful l y when I wan t to w i t h no

d ifficul ty.

ing extra pai n .

B I can look after myse l f normally, but it causes

s l i g h t d i fficulty.

extra pai n .

C I t is pai n ful to look a fter myself and

I am slow

and caref-u l . D 1 need some help, but manage most of my per-

C I have a fai r degree of d i fficulty i n concentrating when I w a n t t o . D I have a lot of d i ffi c u l ty in conce n trat i ng when I want to.

sonal care. E I need help every day in most aspects of self care.

F I do not get dressed,

B I can concentrate ful l y w hen I want to w i t h

I wash w i t h d i fficul ty, and

I stay i n bed .

E I have a great deal of d i fficulty in concen trati ng when I want t o . F I cannot concentrate at a l l .

SECTION 3-Liftil1g

SECTION 7-Work

A I can l i ft heavy weights w i t hout extra pain .

A I can do as m u c h work as I want to.

B I can l i ft heavy weights, but i t gives extra pain . C Pain prevents me fTom l i fting h eavy weights off

B I can o n ly do my usual work, b u t no more . C I can do most of my usual work, b u t no more.

the floor, but I can manage if they are conveniently positioned, for example, on a table. D Pain prevents me from l i ft i ng heavy weights,

D I cannot do my usual work.

E I can hardly do any work at a l l . F I cannot do any work at all .

but I can manage ligh t to medium weights i f they are conveniently positioned .

E I can l i ft very light weights. F I cannot l i ft or carry anything at a l l .

SECTION 4-Reading

SECTION 8-Driving

A I can read as muc h as I want to with no pain i n

A I can drive m y car w i t hout any neck pai n .

my neck.

B I can read as m uc h as I want to w i th slight pai n i n m y neck.

C

I can read as much as I want to with moderate

pain in my nec k . D I cannot read as much as I want because o f moderate pain in my neck.

E I cannot read as much as I want because of severe pai n i n my neck.

F I cannot read at a l l .

B I can drive my car as long as I want w i t h slight pain in my neck .

C I can drive my car as l o ng as I want with moderate pai n i n my neck. D I can not drive my car as long as I want because o f moderate pai n i n my neck.

E I can hardly drive at a l l because o f severe pain i n my nec k . F I cannot drive my car at a l l .

1 74

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NECK PAIN DISABILITY INDEX QUESTIONNAIRE (Continued)

SECTION 9-SZeeping

SECTION j O-Recreation

A I have no trouble sleeping. B My sleep is slightly disturbed ( less than 1 hour

A I am able t o engage i n all of my recreational

sleepless) .

activit i es with no neck pai n at all .

B I am able to engage in all of my recreational

e M y sleep i s m i l d l y disturbed ( 1 -2 hours sleep

activities w i t h some pain in my neck.

e I a m able to engage in most, but not all o f my

l ess). D My sleep is moderately disturbed (2-3 hours

recreational activities because of pain in my

sleepless) .

E My sleep i s greatly d i s turbed (3-5 hours

neck. D I a m able t o engage i n a few of my recreational

sleepless) .

F M y sleep i s completely disturbed (5-7 hours )

activi ties because o f pain i n my neck.

E I c a n hardly do any recreational activities because of pain i n my neck.

F I cannot do any recreational activit ies at all. Patient name

______

Patie n t signature

______

Date

Fonn 4 ( 1 62 ) N e c k D isabi l i ty Index repri n ted w i t h permission from Vern o n H, M ior S . T h e Neck Disabi l i ty I ndex: A study o f rel iabil i ty and val i d i ty. J Manipulative P hysiol Ther 1 99 1 ; 1 4:409-4 1 5.


-

1 75

UPPER EXTREMITY FUNCTION SCALE QUESTIONNAIRE Please indicate w h i c h of the fol lowing t h i ngs you have d i fficulty in doing because of your symptoms. Circle the number that i nd icates how much d i fficulty you have with each activity.

MAJOR PROB LEM (Cannot do it at all)

NO PROBLEM J . Sleep i ng

0

1

2

3

4

5

6

7

8

9

10

2. Writing

0

1

2

3

4

5

6

7

8

9

10

3. Ope n i ng jars

0

1

2

3

4

5

6

7

8

9

10

4. Picking up small objects w i t h fi ngers

0

1

2

3

4

5

6

7

8

9

10

5 . Driving a car more than 3 0 m inutes

0

1

2

3

4

5

6

7

8

9

10

6. Opening a door

0

1

2

3

4

5

6

7

8

9

10

7 . Carry i ng m i l k j u g from t he refrigerator

0

1

2

3

4

5

6

7

8

9

10

8. Wash i ng dishes

0

1

2

3

4

5

6

7

8

9

10

COMM ENTS

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Patient name

______

Pat i e n t signature

______

Date

Form 5 ( 1 26) U pper Extremity Function Scal e reprinted with permission from Pransky G, Feuerste i n M , H i m me l s tein J , Katz I N , Vickers-Laht i M . Measuring functional outcomes i n work-related upper extre m i ty d isorders: Development and validation of the Upper E xtre m i ty Function Scal e s . J Occup E nvi ron M ed 1 997;39:

1 1 95- 1 202.

UPPER EXTREMITY FUNCTIONAL INDEX We are i n teres ted i n knowi ng wheth e r you are having any d i fficul ty at all w i t h t h e act i v i t i es l isted below because of you r upper l i mb problem for w h i c h you are currently seek i ng attention. Please c heck (.I ) an answer for each activi ty.

Today do you or would you have any difficulty at all with,

Extreme Difficulty Or Unable to Perform Activity

Activities

Quite a Bit of Difficulty

Moderate Difficulty

A Little Bit of Difficulty

No Difficulty

Any o f your usual work, household, or sc hool activities Your usual hobbies, recreat ional or sport i ng activi ties L i ft i ng a bag o f groceries to waist level Li ft i ng a bag of groceries above your head Groom i ng your h a i r Pus h i ng up on your hands ( e . g . , from bat htub or c h a i r) Preparing food (e.g. , peeli ng, c u t t i ng) D riving Vacu u m i ng, sweeping, or raking D ress i ng Doing up buttons U s i ng tools or appli ances O pe n i ng doors Cleaning Tying or lacing shoes Sleeping Launderi ng clothes (e.g., wash i ng, i ro n i ng, fol d i ng) Open i ng a jar T h rowing a ball Carrying a small sui tcase with your a ffected l i m b) P a t i e n l name: Score

_______

,/80

_______

Signature:

_______

MDC ( m i n im u m detectable c hange)

=

9 points

Date:

_ _ _ _ _ _ _

Error +/- 5 scale points

Form 6 ( 1 6) Upper E x t rem i ty Funclional Index repri n ted with permi ssion from Stratford PW, B i nkley J M , Strat ford D M . Development and i n i tial val i dation of t h e u pper extremi ty functional i ndex. Physiother Can

200 1 ; 5 3 : 2 59-2 66.

1 76


rL

FUNCTIONAL ASSESSMENT SCALE (FAS)

--

1 77

--------'

_ _ _ _ _ _ _ _ _ _ _ ---_ ---,_

Please respond to the fol lowing ques t i ons, circ li n g only one answer that best describes your abi l i ties.

1.

PAIN: How much pain do you have?

a.

No pain duri ng walking

b.

Occasional ache, does n o t s t o p y o u from walk i ng

c.

M i l d p a i n after walking a long t i me, may take aspirin

d.

Moderate pain wi t h normal walk i n g . May take medication stronger than asp i ri n or Tylenol® a fter excessive activities that cause considerable pai n .

e.

Severe pai n , but able t o walk . M ay need regular medication s t ronger t h a n aspiri n .

r.

Totally disabled w i t h pai n , unable to wal k

2.

WALKING DISTANCE: How far can you walk?

a.

U n l i m i ted d istance

b.

6 blocks 2 or 3 blocks

c. d.

I ndoors, around t h e house only

e.

Bed to c h a i r, unable to walk

3.

WALKING AIDS: How much support do you need to walk?

a.

Ko support needed to walk com fortably

b.

One cane needed for long walks

c.

O n e crutch needed m o s t o f t h e t i m e

d.

Two canes needed m o s t o f t h e t i me

e.

Two crutc hes o r walker needed m o s t of t h e t i m e

4.

STANDING: How long can you stand?

a.

Com fortable standing w i t hout support for 45 m i nutes

b.

Com fortable standing w i t hout support for 30 m i n u tes

c.

Com fortable standing w i t hout support for 1 5 m i n u tes

d.

N o t able t o stand w i t hout support for 1 5 m i nutes

5.

STAIRS: How do you climb steps?

a.

Foot over foot wi thout a banister

b.

Foot over foot with a ban i ster

c.

Using stairs w i t h banister and outside support (example: cane)

d.

Unable to c l i m b stairs

Patient name

______

Patient signatu re

______

Date

Fonn 7 ( 1 77 ) Functional Assessment Score repri n ted w i t h perm ission from Wegener L , K i s ner C , N ichols D . Static and dynam ic balance responses in persons wi t h b i l a teral knee osteoart h r i t i s . J Orthop Sports P hys Ther

1 997 ;25: 1 3- 1 8 .

LOWER EXTREMITY FUNCTIONAL SCALE We are i n terested in know i n g whether you are h aving any d i fficulty at a l l w i t h t h e ac tivit ies l isted below because or your lower l i m b problem for w h i c h you are curren tly seeking attention. Please check (.I) an answer for each activity .

Today, do you or would you have any difficulty at all withExtreme Difficulty Or Unable to Perform Activity

Activities

Quite a Bit of Difficulty

Moderate Difficulty

A Little Bit of Difficu l ty

No

Difficul ty

Any of your usual work, household, or school activities Your usual hobbies, recreational or sporti ng activi t i es G e t t i n g i n to or out o f t he bath Wal k i n g between rooms P u t t i n g on your s h oes or socks Squa t t i ng L i ft i ng an object, l i ke a bag of groceries fro m t he Aoor Perform i ng l ight act ivi t ies around your home Perform ing heavy activit i es around your h o m e Getti ng i n to or out o f a car Wal k i ng 2 blocks Wal king a m i l e Going up or down 1 0 stai rs ( approx i mately 1 R i g h t o r s tairs) Stand i ng ror 1 hour Sitting [or 1 hour R u n n i ng on even ground Run n i ng on u neven ground M a k i ng sharp turns while run n i ng fast H opping Rol l i ng over i n bed Patient name Score

______

_______

/80

Pat i e n t signature

M DC ( m i n i m um detectable change)

=

______

9 poi n ts

Date

Error +/- 5 scale points

Form 8 ( 1 6) Lower Ex tre m i ty Functional Scale repri n ted w i t h perm i ssion from B in kley J M , Stra t ford POW, L o t t SA, Riddle D L. The lower extre m i ty fun c t i onal scale ( LEFS ) : Scale developmen t , measurement propert ies, and clin ical appl icat i o n . Phys Ther 1 999;79: 37 1 -3 8 3 . 1 78


--

1 79

PATIENT SPECIFIC FUNCTIONAL AND PAIN SCALES ( PSFS) Name

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Date

_ _ _ _ _ _

Clinician: Complete a fter the h i story and before t h e physical exami nation Initial Assessment: In you r visits here we want to know what 3 activit ies i n your l i fe you are u nable to do or are having t h e m ost d i fficu l ty w i t h as a resulL o f your c h i e f prob l e m . Please l ist and score a t least 3 activi t i es you are u nable to per form or havi ng t he most d i fficulLy w i t h because of your c h i e f prob l e m .

Follow-up Assessment: When you were assessed on

, you told us that you had d i fficulty w i t h t h e following activities.

Please score the activities you told us previously you were unable to perform or having t h e m ost d i ffic u l ty with because or your c h i e f problem .

Patient Specific Activity Scoring scheme (Point t o one number): o 1 2 3 4 5 6 7 8 9 10 Unable to perform activity

Able to perform activity at same level as before i nj u ry or probl e m

Date and Score Activity 1. 2. 3. 4. 5. Total score = sum of activity scores divided by number of activities average score = 2 points MDC for single activity = 3 points MDC for

Fonn 9 Patient Speci fic Functional Scale repri n ted w i t h permission from Stratford P, G i l l C, Westaway M , B i nkley J . Assessing disab i l ity and change on individual patients: A report o f a patient spec i fi c measure. Physiother Can 1 995;47:258-2 63.

1 80

--


PATIENT SATISFACTION SCALE Here are some ques t i on s about t h e t reatment you h ave been receiving. In terms of your sali sfac tion, how would you rate each of t h e fol l owing? C hoose one response on each l i ne.

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

1 . The doctor gave me enough i n form a t i o n a b o u l t h e cause o f my b a c k pain .

2. T h e doctor d i d NOT give me a c lear explanation o f t he cause of my p a i n .

3 . T h e doctor told m e w h a l t o do to prevent future back problems.

4. The doctor seemed to beli eve that m y p a i n was real .

5 . T h e doctor d i d N O T understand the concerns I had about m y back probl e m . 6 . The doctor d i d NOT seem com fortable dea l i ng with my back pai n .

7 . The doctor was NOT concerned about what happened wi t h m y pain after I l e ft the office.

8. The trea t m e n t the doctor prescribed for my back pain was effect ive.

9. The doctor seemed confident that t h e treatment she/he recom m ended would work.

1 0 . The doctor gave me a clear idea of how long it m i g h t take for my back to get better.

Patient name

_______

Patient signature

_______

Date

Form 1 0 (29) Pati e n t Satisfaction Scale reprin ted w i t h permission from Cherkin D , Deyo RA , Berg AO . Evaluation of a physician education i n t erve n t i o n to i m prove primary care for low-back pai n : II. I mpact on patients. Spine

1 99 1 ; 1 6 : 1 1 73-1 1 7 8 .


--

181

THE BACK BOURNEMOUTH QUESTIONNAIRE The fol l ow i ng scales have been designed to find out about your back pain and h o w it is affecting you. P l ease answer ALL the scales by circ li ng ONE number o n EACH scale that best describes how you feel :

1.

Over the past week, on average, how would you rate your back pai n ? Worst pain possible

No pain

o 2.

2

3

4

5

6

7

8

9

10

Over t h e past week, h o w m u c h has your back p a i n i nterfered w i t h your daily activHies ( housework, washjng, dressing, wal ki ng, c l imbing stairs, getting in/out of bed/c h air) ? U nable to perform activi ty

No i nterference

0 3.

1

2

3

4

5

6

7

8

9

10

Over t he past week, h o w much h a s your back pain i nterfered with your abi l i ty to take part i n recre a t ional , soc ial , and fam i l y activi ties? U nable to perform acti vi ty

No i nterference

0 4.

1

2

3

4

5

6

7

8

9

10

Over the past week, how anxious ( tense, u ptight , i rri table, d i fficulty i n concentrating/relaxing) have your been fee l i ng? Extremely anxious

Not at all anxious

0 5.

1

2

3

4

5

6

7

8

9

10

Over the past week, how depressed (down-in-the-dumps, sad, i n low spirits, pessim istic, u n h appy) have you been fee l i ng? Extremely depressed

Not at all depressed

o 6.

1

2

3

4

5

6

7

8

9

10

Over the past week, how have you felt your work (both i nside and outside the home) has affected ( or would affect) your back pai n ? Have made i t m uc h worse

Have made i t no worse

0 7.

1

2

3

4

5

6

7

8

9

10

Over t h e past week, h o w m u c h have you been able t o control (reduce/help) your back p a i n o n your own? Completely control it

o

1

Patient name

2

No control whatsoever

3

4

5

______

6

7

Patient signature

8

9

10

_______

Date

Form 1 1 (2 1 ) Bournemout h Back Questionnaire reprinted w i t h perm issi o n from Bolton J E , Breen A C . The Bournemouth Questionnaire : A short-form comprehensive outcome measure. I. Psychometric properties in back pain patients. J Manipula Physiol Ther 1 999;22: 503-5 1 0.

1 82

--


THE NECK BOURNEMOUTH QUESTIONNAIRE The rol l ow i ng scales have been designed to find out about your back pain and how it is affect i ng you . Please answer A L L t h e scales by c i rcl i ng O NE n u m ber on EACH scale that best describes how you feel :

1.

Over the past week, on average, how would you rate your neck pai n ? No pain

Worst pain possible

o 2.

2

3

4

5

6

7

8

9

10

Over t h e pas t week, how m u c h has your neck pain i n terfered w i t h your daily activi ties ( housework, was h i ng, dress i ng, l i fting, rea d i ng, driving) ? N o i n terference

o 3.

Unable to perform activity

2

]

3

4

5

6

7

8

9

10

Over t h e past week, h o w m u c h h as your neck pain interfered w i t h your a b i l i ty t o take part i n recre a t i o n a l , soc i a l , and fami l y activi t i es ? N o i n terference

o 4.

1

U nable to perform activi ty

2

3

4

5

6

7

8

9

10

Over t h e past week, how anxious ( tense, u p t i g h t , irri table, d i fficulty i n concentrati ng/relaxing) have you been feel i ng? Not at all anxious

0 5.

1

2

Extremely anxious

3

4

5

6

7

8

9

]0

Over t h e past week , h o w depressed ( down-in-t he-dumps, sad, i n l o w spirits, pess i m istic, unhappy) have you been feel i ng? N o t at a l l depressed

o 6.

]

2

Extremely depressed

3

4

5

6

7

8

9

10

Over t h e past week, how have you felt your work ( b o t h i nside and outside the h o m e ) h a s a ffected ( o r would affect ) your n e c k pai n ? H ave made i t n o worse

0 7.

1

2

H ave made it much worse

3

4

5

6

8

7

9

10

Over the past week, h o w much have you been a b l e to control ( reduce/help) your neck pa in on your own? Compl etely contro l i t

o

]

Patient name

2

N o control whatsoever

3

4

5

______

6

7

P a t i e n t signature

8

9

10

_______

Date

Form 12 (22) Bournemouth Neck Quest i o n n a i re repri n ted w i t h permi ssion from Bol ton JE, H u m p h reys BK. The Bou rnemouth Quest i o n n a i re : A short-form comprehensive outcome measure. II. Psychometric propert ies i n neck pain patients. J Manipula Physiol Ther 2002;25 : 1 4 1 - 1 48 .

Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

Craig Liebenson and Steven Yeomans

Introduction Risk Factors of Chronicity Phase of Care Psycho-Social and Other Factors

Learning Objectives

After reading this chapter you should be able to understand: •

Fear-Avoidance Beliefs Cervical and Upper Quarter Risk Factors

•

Assessment The Waddell Nonorganic Low Back Pain Signs Introduction The Prognostic Value of the Waddell Signs Evaluation Nonorganic Neck Pain Signs

•

•

The prognosis for acute low back pain becoming chronic What prognostic factors have been identified to predict the risk of acute back or neck pain becoming chronic How to capture a "yellow flags" score reliably and efficiently Which prognostic risk factors are amenable to intervention and what type of intervention is appropriate

Treatment for Patients with High "Yellow Flags" Scores

183

184

--


Introduction ..

: ..

.. .

.

.. ..

I s i t possi ble to i n crease the qual ity and efficiency of care by stratirying acute or subacute pat ients i n to groups that are ei t her more or less likely to recover, and thus match them to more or less aggressive management?

It is a commonly held belief that acute low back pain (LBP) resolves within 4 to 6 weeks for most indi viduals (750/0-90%) (45,107). This is primarily based on insurance surveillance data concerning disability. Such an optimistic picture has led to false confidence in a passive management philosophy involving symp tomatic approaches (bed rest and medication) or a non-management approach of leaving it alone to let "nature run its course." However, there are two prob lems with this perspective. First, the view that most acute episodes resolve quickly and completely is dis puted by a number of studies of primary care patients (13,22,117). Second, there is a growing body of evi dence that it is more cost-effective to prevent chronic ity in those at risk for it rather than waiting to treat only those in whom it becomes fully apparent. Von Korff et al demonstrated in a non-occupa tional setting that after 1 month only 30% of neck and low back pain patients had achieved pain-free status, and after 1 year 50% still reported recurrent or persistent pain (117). Most recent studies show that the majority of acute episodes tend to improve rapidly, although not completely, and then run an intermittent chronic course with less severe "flare ups." The original episode frequently lasts for as long as 3 months-not 4 to 6 weeks-before it can even be said to have remitted (13,22). The "flare-ups," which are predictable in the majority of cases 1 year later, are mild to moderately activity-limiting and painful and lead to general dissatisfaction with the symptoms (13,2 1,22, 1 17). Thus, back problems typically run recurrent or chronic remitting courses with occasional acute self-limiting episodes. Even though only a small percentage (7%) of indi viduals with acute LBP have chronic unremitting pain and disability, this group accounts for the majority of the costs (11,107). More specifically, 7.4% of patients account for approximately 75% of all the costs and 85% of the disability days (50,107). Thus, identifying potential risk factors for acute pain becoming chronic has become a "holy grail" of LBP research (1). Risk Factors of Chronicity

Assessment of spine patients has traditionally focused on finding the physical cause of the pain. Imaging techniques have figured prominently in this endeavor.

Unfortunately, this has been an inefficient use of resources because of the poor specificity of this expen sive screening approach (4,5,7,54,57,58,64,1 1 1, 1 24). Clinical scientists have summarized that the follow ing measurable outcomes are representative criteria of patient recovery: pain, function (disability), well being, work status, and satisfaction (6,25). According to Pinchus et aI, the risk of long-term LBP-related activity limitations (disability) and work loss (partici pation) arises from four main sources that interact with each other (Table 9. 1 ) (94). Individual factors have been referred to as psychosocial "yellow flags" (63). "Yellow flags" are analogous to the concept of "red flags" in that they both influence the manage ment and prognosis of the patient. Whereas "red flags" are indications for biomedical laboratory or imaging investigations and possibly specialist referral, "yellow flags" are indications for investigating the cognitive, affective, and behavioral aspects of LBP. Most yel low flags pertain to individual or work related factors, yet the effect the treatment provider has on outcome is also important (23,99). Reis et al evaluated both the patients ' and clinicians' percep tions of worry, coping, limitations, expectation of pain relief, and pain interference. When evaluated individ ually, both patients' and clinicians' perceptions were found to predict outcome at 2, 4, 8, and 12 months. Because many patient characteristics are stable and thus non-responsive to change (such as premorbidity, high levels of depression, and catastrophizing), other risk factors that may be amenable to change such as patients' or clinicians' perceptions and expectations should receive greater attention. The influence of perception on outcom� is high lighted by Kalauokalani et al.'s study of 135 patients with chronic LBP who were allocated randomly to receive either massage or acupuncture (6 1 ). Patient expectations regarding the potential helpfulness of each treatment correlated more than other variables with subsequent functional outcomes as assessed at 1 0 weeks using the modified Roland Score.

Phase of Care

Because the majority of acute patients have a very good prognosis overly aggressive early management

Table 9.1 Four Main Factors that Influence Chronic Disability [from Pinchus et al (94)] • • • •

Individual Treatment provider Compensation or health care system Workplace or home environment

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Vellow Flags"

is an inefficient use of limited health care resources. However, the same cannot be said for patients who are still symptomatic in the subacute phase. Thus, the subacute phase, beginning at the end of the first month, has now been recognized as a critical period when more aggressive management strategies can potentially have a large impact on preventing chronic pain and disability and thus reducing costs (32). Frank has presented the concept of the "number needed to treat" to determine the cutoff for when it would be more efficient and cost-effective to substi tute more aggressive treatment for less aggressive approach. He states that it is possible to show that "the number (of individuals) needed to treat" to pre vent a single case fTom passing into chronicity at 6 months off work declines swiftly over the first month and then remains rather stable" (32). According to Frank, there are three distinct stages in terms of risk of an acute episode becoming chronic (Fig. 9.1)(32). In the acute stage (first 4 weeks), the risk of chronicity is low. In the subacute stage (weeks 4-12), the risk is high "ipso facto" and the survival curve suggests aggressive treatment will be cost-effective here. In the chronic stage (after 12 weeks) recovery halts. This is borne out by a recent study of worker's com pensation claimants, in which it was found that the most robust predictors of future status (recurrence likelihood) were preadmission health care visits and more previous back-related claims (43).

Psycho-Social and Other Factors

Do Structural or Psychologic Factors Predict Future Disabling LBP? A prospective, longi t u d i nal study of 100 subjects with mild persistent low back pai n and a predispos i t ion to disc degenerat ive disease was performed. The development of d isabling LBP over a 5-year period was strongly predicted by base l i n e psychosoci al variables (p_

�� e(fJ Ql ()

Q; Cl.

40% 20%

II

III

O%""+O""rnho"""""rn�"""rn�",,,,� 15 50 35 20 40 30 25 45 o 12 weeks Time (Weeks) Since Pain Onset 3 to 4 weeks

Figure 9.1

Three-phase model of low back pain natural history ( 3 2 ) .

From Frank J W , Kerr M S , Brooker AS, et al . D isab i l i t y resul t i ng [yom occupational low back pai n . Part 2: W h at do we know about secondary prevention? Spine 1996;2 1 :2 9 18-2 929.

J 85

reported disability (Roland-Morris scale) (87). Six separate review papers of varying methodologic rigor all agreed that psychological characteristics such as coping strategies, self-efficacy beliefs, fear-avoidance behavior, and distress are examples of relevant fac tors than can be identified (31,55,73,76,94,114). Thus, the presence of psychosocial "yellow nags" indica tive of a decreased likelihood of recovery has been proposed as a technique for early identification and matched appropriate management of those with a poorer prognosis (63,77,79,81,100,118).

Psychological variables have been demonstrated to account for 26% of self-reported pain and 36% of self-

C

--

(conlinued)

J 86

--


•

Do Structural or Psychologic Factors Predict Future Disabling LBP? (Continued) • •

E p isodes of aJl back pain symptoms at least 6 months Medical visits primarily for LBP evaluation and U-eatment

CalTagee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial detel-minants of low back pain disability and remission: A prospective study in subjects with benign per sistent back pain. Spine 2005;5:24-35.

Gatchel et al. generated a statistical algorithm to iden tify acute patients at risk for chronic painidisability (40). By including factors such as gender, self-reported pain, and disability scores, scores on Scale 3 (hysteria) of the Minnesota Multiphasic Personality Inventory (MMPI), and workers' compensation and personal injury status, 90.7% of cases could be correctly classi fied as high or low risk for chronic pain/disability. The hysteria subscale of the MMPI had an odds ratio of 1.5 for predicting return to work. Thus, individuals with hjgh hysteria scores on the MMPI are 1.S-times more likely to have chronic LBP than those without such scores. The large Boeing prospective trial also found this scale was predictive of future work-related injury (3). However, this is considered to be of minimal util ity because it reflects personality, which is considered a trait measure that is not sensitive to change (94). Further validation of this model showed that a number of other factors also correlate with high risk (98). A less positive temperament identified with the Schedule for Nonadaptive and Adaptive Person ality (SNAP), high workaholism (SNAP), an avoidant coping style, and an axis I (psychiatric) disorder were found to predict with 80.8% accuracy (80% sensitivity and 81.5% specificity) whether a person was at high or low risk for chronic LBP (98). Fransen et al. also showed that early identification of risk factors can predict time off work because of back pain (33). This theoretically should lead to tar geted interventions to those individuals at greatest risk for future disability. It was found if workers, at the time they make their initial claim for workman's com pensation, report any of the following that the odds that they will still be receiving compensation 3 months laler will be significantly increased: • •

• •

a workplace unable to provide light duties on return to work

The authors concluded, "Importantly, these deter minants each retained significant associations with chronic occupational back pain, even when statisti cal adjustments were made for age, gender, and the other significant individual, psychosocial, or work place risk factors" (33). Schultz et al. found lhal cognitive factors were the most predictive of time off work for low back pain over a 3-month period (102). Cognitive beliefs relating to perceptions of current health, physical status, and expectations of recovery were most relevant. Another very important predictor was sciatica. The overall correct prediction rate was 77.6%. Thomas and colleagues performed a prospective study that followed 5000 asymptomatic individuals for 18 months and correlated pre-morbid and clini cal factors with development of chronic LBP (112). Ten percent of these individuals had LBP, with 34% of these reporting persistent, disabling LBP at 1 week, 3 months, and 12 months after onset. The premor bid features which correlated with persistent, dis abling LBP were: sex (female), age (increasing), high psychosocial distress, below average self-rated health, low level of physical activity, history of LBP, and job dissatisfaction. Each of these had a 2- to S-fold effect on the odds of being associated with persistent symptoms.

Psychological Characteristics of Acute LBP Individuals Predicts Future Distress, Pain and Impairment

Subjects:

76 acute LBP i ndividuals

Methods:

Pain Anxiety Symptoms Scale was admi nis

tered

Results: •

The cognitive d i mension of the scale predicted future affective distress, locus of control, and pain severity

•

The escape and avoidance d imension pred i cted i m pa i rment i n activi t i es of daily l iving

Vowles KE, Zvokensky MJ, Gross RT, Sperry lA. Pain-related anxiety in the prediction or chronic low-back pain distress. J Behav Dis 2004;27:77-89.

severe radiating lower limb pain at least moderate physical disability (Oswestry) psychological distress the need to lift for at least three-fourths of the day

The episode specific factors that correlated with the development of persistent disabling LBP were the presence of widespread pain, long duration of symp toms before consultation, leg pain, and significant restrictions in spinal movement. Widespread pain was

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-uYellow Flags"

the most highly correlating item with an odds ratio of 6.4. The other factors were associated with a 2- to 5-fold increased chance of poor outcome. Only 6% of patients with a poor outcome were missed if a mini mum of three factors were used to identify risk!!! Shaw et aJ. showed that low back disability was related to the following problem-solving approaches: problem avoidance, lack of positive problem-solving orientation, and impulsive decision-making (104).

Fear-Avoidance Beliefs

One of the major goals of care is to reduce activity intolerances associated with pain (2,81). Thus, the cognitive association of activity with pain or anticipa tion of pain is an important psychological construct (14,24,95,101). In fact, the belief that an activity will be painful has been shown to be more predictive of physical performance than purely nociceptive fac tors (68,69). Anxious patients predict pain sooner during the performance of physical tasks such as range of motion (ROM) or straight leg raise tests (14,15,24). Council et aJ. documented substantial cor relations between pain expectancies and self-rated physical disability with the performance of simple motor tasks (22). It is important to distinguish those factors that are associated with chronic pain from those that predict it. For instance, Ciccione showed that depression, soma tization, and current pain ratings combined to explain 34% of the variance in work disability in a chronic group (15). However, these factors explained only 8% of the variance in an acute sample! More significant is the finding that pain expectancies accounted for 33% of the variance in acute subjects (P < 0.001) (15). Fritz et al. has also confirmed that initial fear-avoidance beliefs were significant predictors of subacute status at 4 weeks independent of pain intensity, physical impairment, disability, or therapy received (34,35). Thus, fear-avoidance beliefs such as pain expectancies begin in acute pain and precede other psychosocial problems that develop as acute pain becomes chronic. Linton and colleagues found that fear-avoidance beliefs were even prospectively related to the devel opment of acute pain and dysfunction in asympto matic individuals (75). Those with scores above the median had twice the risk for acute LBP (odds ratio 2.4). Catastrophizing was also evaluated, but its predictive power was more limited (odds ratio 1.5). Although numerous studies demonstrate the effec tiveness of cognitive-behavioral strategies (30,36,65, 74,80,95) simpler re-activation approaches may be all that is needed. Mannion reported that three differ ent active care approaches, none of which consisted of psychological or cognitive-behavioral approaches,

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J 87

all improved psychological variables related to self report of pain and disability (87). Abnormal illness behavior contributes to a slower or inadequate recovery (92,97). Patients who equate hurt with harm develop a disabling form of thinking. They develop fear-avoidance behavior that promotes deconditioning (Fig. 1.9) (8 1 ,116). It is important to identify the patient who is fearful and avoid encourag ing them to take on a "sick role." According to Troup (113), "If fear of pain persists, unless it is specifically recognized and treated, it leads inexorably to pain avoidance and thence to disuse."

Cervical and Upper Quarter Risk Factors

Tenenbaum et al. has shown that whiplash-associated disorders classification II patients with neuropsycho logic problems have a worse prognosis over a 3-year follow-up period (110). Confidence in 'one 's ability to work after 2 years is correlated with 3-year outcome (P < 0.0001) for neck pain caused by whiplash (91). Carroll et al. have demonstrated that high levels of pas sive coping are associated with disabling cervical or lumbar spine pain (10). These patients have difficulty functioning with pain, are less likely to take responsi bility for care, and have lower self-rated health. Macfarlane et al. performed a prospective study aimed at determining the relative contributions of psychological and work-related factors in the onset of forearm pain (82); 1953 individuals were followed up for 1 year and 105 (8.3%) developed forearm pain. Increased risks for forearm pain were associated with a number of factors. Psychological distress had a relative risk (RR) of 2.4 (95% confidence interval 1.5-3.8). Multiple areas of pain had a RR of 1.7 (95% confidence interval 0.95-3.0). Repetitive movements of the arm had a R R of 4.1 (95% confidence interval 1.7-10), whereas that of the wrist was 3.4 (95% con fidence interval 1.3-8.7). Dissatisfaction with a col league or supervisor support had a RR of 4.7 (95% confidence interval 2.2-10). Hill et al. recently reported that the most impor tant factors related to persistent neck pain were age (51-68), concomitant LBP, and regular cycling (53). Age was by far the most significant factor. Both age older than 40 and concomitant LBP were also found to be accurate predictors by Hoving et al. (56). Other authors have has reported that concomitant LBP was a significant prognostic factor for chronic neck pain (20,72,86,93). Feuerstein (29) followed acute «6 weeks from onset) cervical and upper quarter pain patients for up to 1 year to ascertain what factors were predictive of I -month, 3-month, and 12-month outcomes. The findings are summarized in Tables 9.2 and 9.3.

188

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Table 9.2 Risk Factors for Prolonged Cervical and Upper Quarter Pain (29) 1 month • Upper extremity co-morbidity (RR 1.58) • Pain severity (RR 1.45) • Ergonomic risk factor (RR 1.07) • Low job support (RR 1.03) • Catastrophizing pain coping style (RR 1 .54) 3 months • Pain severity (RR 10.46) • Job stress (RR 1.20) • Catastrophizing pain coping style (RR 1.98) 12 months • Number of pain treatment episodes (RR 1 .77) • Past recommendations for surgery (RR 6.43) • Catastrophizing pain coping style (RR 1.87)

Assessment

Linton reviewed psychological risk factors in back and neck pain with the objective to summarize cur rent knowledge concerning the role psychological factors play in the cause and development of back and neck pain (76). In doing so, 913 potentially rele vant articles were located and 37 studies consisting of only those with prospective designs to ensure qual ity. The review procedure resulted in the reporting of the main predictor variables and the outcome crite ria. If a statistically significant relation was deter mined, a plus (+) or minus (-) was used to indicate a positive or negative association, respectively. If no sta tistical significant relationship was found, a zero (0) was used. The conclusions include a grading system similar to that used for meta-analysis review and guidelines preparation (78). These grades include the following:

Level C: Inconclusive data exist Level D: No studies were found to meet the crite ria utilized Table 9.4 offers a summary of the conclusions drawn from this review of prospective studies. What follows is a list of those specific risk factors called "yellow flags"-for acute LBP pain becoming chronic. These have been identified primarily from an assortment of prospective longitudinal studies. Few cross-sectional studies were used as sources for the "yellow flags." They are divided into those related to symptoms, examination, psychosocial, functional, and work-related factors (Table 9.5). "Yellow flags" are primarily subjective and have a significant psycho social predominance. Whereas "red flags" such as cauda equina syndrome, cancer, fracture, and infec tion require urgent attention, further testing, and possibly specialist referral, "yellow flags" only require a shift in the focus of care. These risk factors have been reported to predict Couture chronic pain or dis ability in the United States (13,51,83,84), New Zealand (63,77,79), and in England (8). Subjective psychologic screening through the his tory taking has low sensitivity and predictive value for identifying distressed or disabled patients, thus for mal screening of some sort such as with a question naire is recommended (42,46). A 2-item screening test for depression taken [Tom the Primary Care Evalua tion of Mental Disorders Procedure (PRIME-MD) was found to be more accurate in screening for depressive symptoms than a physical therapist 's own subjec tive ratings, even for individuals with severe depres sion (46). Many of these factors can be captured with a simple easy-to-administer form (see appendix). Linton has suggested the ideal cutoff for consid ering one definitely at risk is a score of 50% or more ' or 65 or more points out of 130 points (77,79,81). •

Level A: Evidence is supported [Tom two or more good-quali ty prospective studies Level B: Evidence is supported from at least one good-quality prospective study •

Table 9.3 The Sensitivity and Specificity of Cervical and Upper Quarter Pain Predictors (29) Duration

Sensitivity

Specificity

1 month 3 months 12 months

77.4% 80.6% 80.6%

71.8% 82.4% 83.3%

•

•

At this level, the specificity is 75% (people with lower scores who are correctly predicted not to develop chronic disability) and sensitivity is 86% to 88% (people with higher scores who are correctly predicted to develop chronic disability). If the cutoff is higher, specificity may increase, even up to 88%, but sensitivity can be com promised down to 34%. If the cutoff is lower, sensitivity may increase to more than 90%, but specificity can be compromised down to less than 50%. Therefore, the utility of the YF screen depends on the need to know the patients who are at risk versus the need to avoid mislabeling people at risk.

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

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189

Table 9.4 Grading System for Evaluating Prospective Psychological Risk Factors of Neck and Low Back Pain Chronicity Evidence Level

Risk Factor 1. Psychosocial variables are clearly linked to the transition from acute to chronic pain disability.

Level A

2. Psychological factors are associated with reported onset of back and neck pain

Level A

3. Psychosocial variables generally have more impact than biomedical or biomechanical factors on back pain disability

Level A

4. No evidence exists to support the idea of a "pain-prone" personality link

Level D

5. Results are mixed with regard to whether personality and traits are risk factors

Level C

6. Cognitive factors (attitudes, cognitive style, fear-avoidance beliefs) are related to the development of pain and disability a. Passive coping is related to pain and disability b. Pain cognitions (e.g., catastrophizing) are related to pain and disability c. Fear-avoidance beliefs are related to pain and disability

Level A

7. Depression, anxiety, distress, and related emotions are related to pain and disability

Level A

8. Sexual ancIJor physical abuse may be related to chronic pain and disability

Level D

9. Self-perceived poor health is related to chronic pain and disability

Level A

10. Psychosocial factors may be used as predictors of the risk for developing long-term pain and disability

Level A

Reproduced wIth permIssIon fyom Lmton SJ . A revIew o f psychologIcal nsk factors m back and neck pam. Spme 2000, 9:1148-1 1 56 .

Clinical Pearl It is recommended that a screen of "yel low flags" be performed on the first visit for all spine pai n pat ien t s .

would be suitable for a more cognitive-behaviorally oriented treatment program coupled with functional rehabilitation aimed at reducing activi ty intolerances and physiologic impairments.

The Waddell Nonorganic Low

If the "yellow flags" screen is delayed, then it cer tainly should be performed as part of the biopsy chosocial re-evaluation of a patient who is not recovering satisfactorily at the 4- to 6-week mark. Many of the variables are also worthwhile outcomes of care and can be reassessed at regular intervals (every 4-6 weeks) in the same way as other outcome measurement tools such as the Oswestry or Neck Disability Index questionnaires are utilized. Two simple questionnaires, the Tampa Scale for kinesiophobia (17 items) and the fear-avoidance beliefs ( 1 6 items), were shown to have good internal consistency, test-retest reliability, and concurrent validity for assessing pain-related fear in acute LBP patients(108). All patients had LBP for no more than 4 weeks. This study demonstrates that patients can be classified early as having a psychosocial component to their pain. The implication is that such patients

Back Pain Signs

Introduction

The Waddell non-organic signs are used as objective measures for evaluating abnormal psychosocial issues in patients with low back pain (118). Contrary to the premise behind provocative orthopedic tests in which pain reproduction to identify the specific pain generator is the goal, the objective when perform ing the non-organic tests is to purposely not try to provoke pain. It can sometimes be difficult to dis criminate between patients with a physiological or organic explanation for the test response; therefore, repeating the test a few times to assure evaluator reliability is recommended. Hence, these tests must be performed and interpreted carefully, because apply ing the test too vigorously can result in a false-positive result.

190

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Table 9.S

Yellow Flags Risk Factors for Acute LBP Becoming Chronic

History and Symptoms • Duration of symptoms 4-12 weeks (112) • Sciatica (8,13,33,70,90,103,112) • History of previous episodes of back pain requiring treatment (8,13) • Severe pain intensity at 3 weeks (8); at 4 weeks (26); at 6 weeks (41); and at 8 weeks (28) • Delaying treatment at least 7 days (90,115) • Widespread pain (112) Examination • Positive straight leg raise test (8,19,66,71) • Positive neurological examination (motor, sensory, reflex) (47,66,52) • Positive range of motion (ROM) or orthopedic findings (47,52,68,109,112) • Lack of centralization of peripheral symptoms with repetitive ROM testing (123) Psychosocial • 3 or more Waddell signs of illness behavior (70,90,122); no (33) • Self-rated health as poor (10,112) [(26) at 4 weeks] • Symptom satisfaction (13) • Fear-avoidance beliefs (3 questions) [(26) at 4 weeks] (34,49,66,77-79) o belief that physical activity makes pain worse belief that if person has pain with activity they should cease the activity o belief that person with pain should not perform normal activities with pain • Anxiety (14,79,80,94) • Coping (praying, hoping, catastrophizing) (8,70) [large effect sizes (94)] • Distress/depression (22,27,77,108) [odds ratio approximately 3 and medium magnitude effect size (94)] • Poor locus of control (yes: 47,70,77-79) (no: 8,88) • Low expectation of recovery (51,77-79) • Blaming others (90) Negative family or workplace social situation (90) • • Increased number of children being cared for (47) • Anticipation of future disability or ability to return to work (51,77,78) o

Work-Related • Receiving compensation (90) • Litigation (90) • Physically demanding job (or perception of) (47,51,33) • Job dissatisfaction (3,12,13,19,112,125) (no: 77-79) • Subjective work-related ability (47) • Prior disability in the prior 12 months (77-79) • A workplace unable to provide light duties on return to work (33) • Low job control or low supervisor support (60) Functional • Light work tolerance (77-79) • Sleep (77-79,90) • At least moderate physical disability (score of 201100 or higher with the Oswestry) (33)

The Prognostic Value of the Waddell Signs

The Waddell signs for low back pain have been widely utilized because they have been reported to help iden tify patients with underlying significant psychologi-

cal distress (118,122). Many studies have identified non-organic behavior using the Waddell signs as pre dictors of suboptimal surgical and rehabilitation outcomes (16-18,27,62, 1 18, 1 19). Gaines and Heg mann (39) reported in LBP subjects that the presence of even only one sign delayed the median time to


return to work by almost four times (58.5 vs. 15 days) and was associated with an increased use of physical therapy and CT scanning. Fritz and colleagues used the non-organic signs as a screening tool to determine when it was safe to · return acute low back pain patients to work (34). The best cutoff values were two or more signs (neg ative likelihood ratio 0.75), three or more symp toms (0.62), and an index score of three or more (0.59). The authors reported that even with optimal cutoff values, none of the nonorganic tests served as effective screening tools for early identification of acute LBP patients at increased risk for delay in returning to work. Similarly, Polatin and col leagues reported no significant associations be tween Waddell total positive score or changes in score and therapeutic success as measured by any of the behavioral outcomes such as return to work in a cohort of patients with chronic, long-term low back pain (96). The relationship of Waddell signs and the Min nesota Multiphasic Personality Inventory (MMPI) has also been reported (89). Waddell's original article re ported that a low but consistent con-elation existed between non-organic physical signs and the first three MMPI scales (hypochondriasis, Hs; depression, D; hys teria, Hy) (118). Maruta et al. found that among male patients, MMPI scales 1 (Hs), 3 (Hy), and 8 (schizo phrenia, Sc) and high Waddell signs (3-5 signs) were found to correlate with statistically significance, but among the female patients, none of the first three scales con-elated, only MMPI scale 8. In a work-disabled population, non-organic signs were compared to the centralization phenomenon of McKenzie as predictors of the return to work rate (62). The authors reported that the Waddell score was more predictive of the work return outcome compared to the centralization of symptoms. In 1998, Main and Waddell (85) published a "reap praisal" of the way the non-organic signs should be interpreted. They stressed that isolated signs should not be over-interpreted and that multiple signs sug gest that the patient does not have a straightforward physical problem. Psychological factors that coexist with physical conditions may require both physical management of the structural pathology and a psy chosocial and behavioral management of their illness. They also stress that the signs are not by themselves, a test of credibility or faking. =

Evaluation

There are five signs that are evaluated. The presence of three out of five of these signs is significantly cor related with disability (l18). The signs are:

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19 1

1) Superficial or nonanatomic tenderness-wide spread sensitivity to light touch in the lumbar region and pain referred to other areas such as thoracic, sacrum, or pelvis. 2) Simulation-axial loading (light pressure to the skull should not significantly increase low back pain. Passive rotation of the shoulders and pelvis together in a standing patient should not repro duce low back pain. 3) Distractions-difference of 40 to 45 degrees between the supine and seated straight leg rais ing tests. 4) Regional disturbances-sensory or motor distur bance ("giving way") that is not neurologically correlated. 5) Overreaction-inappropriate overreaction such as guarding, limping, rubbing the affected area, bracing oneself, grimacing, or sighing are all signs of illness behavior. Because three of the five signs include two separate tests, there are a total of eight tests that make up the five Waddell signs. For those signs that include two tests, if either of the two tests is positive, a positive sign is reported. In other words, it is not necessary for both tests to be positive to result in a positive sign, but rather only one of the two tests. The final score is doc umented as the total number of positive signs over five (e.g., 2/5). Non-organic LBP must be considered and the psychosocial issues clinically addressed when three or more of the five signs are positive. Wernecke et al. found that these behavioral signs could be improved by a physical rehabilitation program ( 1 22). Waddell's signs were shown to be an integral com ponent of a broader assessment of risk for non return to work in chronic LBP individuals (67). The full assessment also included measurement of pain intensity, a step test, and a pseudo-strength test. If two of the four tests were positive, correct prediction of risk occurred with a positive predictive value of 0.97 and sensitivity of 0.45. Pain intensity was posi tive if the Numeric Rating Scale (0-10) score was 9 or 10. The step test was performed for 3 minutes and was positive if the patient stopped it prematurely (see Chapter 1 2). The pseudo-strength test involved the patient holding two 3-kg weight with straight arms against gravity for 2 minutes. The test was pos itive if the test was stopped prematurely. According to Waddell this examination should not be performed on acute patients (118).

1) Tenderness a) Superficial: Superficial tenderness is defined as widespread sensitivity to light touch of the skin over the lumbar spine. This is evaluated by applying light touch over the lumbar skin

192

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Figure 9.2

Waddell s ign-superfi c i al tenderness.

floor (Fig. 9.3). A modification of applying the pressure to the shoulders is suggested to avoid cervical spine symptoms.

in a manner that should NOT normally pro voke pain (Fig. 9.2).

b) Non-anatomic: Non-anatomic is defined as bone tenderness over a wide area, often extend ing to the thoracic spine, sacrum, or pelvis. This is characterized by a non-anatomical, wide area of pain, not localized to one struc ture or anatomical region. 2) Simulation

b) Trunk rotation: do not turn the shoulders more than the pelvis when trunk rotation is applied (Fig. 9.4). 3) Distraction: Sitting Versus Supine Straight Leg Raise (SLR) •

a) Axial compression: apply light downward pressure on the head in the direction of the

Figure 9.3

Sitting distracted SLR (simultaneous testing of the plantar reflex) and supine undistracted SLR (Figs. 9.5A and B)

Waddell sign-s i mu l aLion, axial compression.


Figure 9.4 (A)

and

(B) Waddell

4) Regional Disturbance a) Motor (Fig. 9.6A)

b) Sensory (Fig. 9.6B)

193

sign-si mulation, tnll1k rotation.

More lhan a 40-degree difference was defined as significant This is somelimes referred lo as a positive "flip" sign as lhe palient is "flipped" from supine to sit ting (or vise versa). •

--

Positive test: non-analomical neurological loss and/or inconsislency on repeated testing • Findings may include (bul are nol limiled to): breakaway weakness, multiple weakness in an extremity (n.de oUl pain induced vs. fear-induced weakness), global or patchy altered sensory findings 5) Exaggeration/overreaction

Figure 9.5 (A)

•

and

(B) Waddell

versus supine straight leg raise.

sign-d i strac t i on: s i l t i ng

194

--


Figure 9.6 (A) Waddell sign-regional d i sturbance, m otor. (B) Waddell sign-regional d isturbance, sensory.

This sign includes an inappropriate response at any time during the entire physical examination when exaggeration, overreaction, or a disproportionate response such as a tremor, outcry, or collapse occurs (Fig. 9.7). A list of descriplors includes the following: • • •

•

•

Assisted movemenl (cane, walker, furniture) Rigid or slow movement Bracing: both limbs supporting weight while seated Rubbing the affected area for more than 3 seconds Clutching, grasping affected area for more lhan 3 seconds

•

Grimacing

•

Sighing with shoulders rising and falling

Nonorganic Neck Pain Signs

Sobel and colleagues developed and assessed the reli abililY of a group of non-organic signs applicable to neck pain palients (l06). Twenty-six consecutive patients wilh neck pain histories of more than 4 months were evaluated by two health care providers for the presence of cervical nonorganic signs. As pat lerned after the low back pain signs of Waddell, the five signs consist of seven tests as follows:

Figure 9.7

Waddell sign-exaggeration/over-reaction .

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Vellow Flags"

1.

Tenderness a.

Superficial: patient reports pain with light touch or pinching

h. Non-anatomical: widespread tenderness out side of the cervical/upper thoracic .region to deep palpation

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195

Weaver et al. reported that Waddell signs are an efficient way to identify chronic LBP patients that may be either depressed or anxious (121). The study also suggested that the presence of even just two signs is correlated with more depressive and anxiety symptoms.

2. Simulation Rotation of the head/shoulders/trunklpelvis while standing

3. Range of motion Patient rotates neck right and left as far as possi ble (positive if >50% deficit in either direction)

4. Regional disturbance a.

Sensory loss: light touch or pinprick decrease that is non-anatomical

h. Motor loss: manual muscle testing with non anatomical weakness with "giveway weak ness" or observed normal strength but weakness when formal tests are performed 5. Overreaction At any time during the examination, any of the following are observed: •

•

•

Moderate to extremely stiff, rigid, or slow movements Rubbing the affected area for more than 3 seconds Clutching, grasping, or squeezing the area for more than 3 seconds

•

Grimacing because of pain

•

Sighing

•

Disproportionate verbalization

•

Muscle tension

The percent of agreement between the two raters ranged between 68% and 1 00% with simulation (seated test) being the lowest (68%) and regional sen sory disturbance being the highest ( 1 00%). The aver age agreement was 84.6% and the kappa coefficients ranged from 1.00 to 0.16. As the number of positive signs increased, so did the percentage of agreement. This ranged from 77% agreement with a kappa of 0.44 for one sign to 92% agreement (kappa 0.76 for five signs). The test is considered positive if three of five signs are present (106). Similar to Waddell in his description of the low back pain tests, the authors discussed the importance of care being taken when assessing for over-reaction. This is because over-reaction is very subjective given the cultural variations in response to painful maneu vers as well as the evaluator's own emotional feelings about the patient.

Treatment for Patients with High "Yellow Flags" Scores

The results of the "yellow flags" scoring instrument should be used for three purposes: first, to make an informed comment on prognosis; second, to steer care toward the most appropriate interventions; and third, to document patient progress with reli able outcomes. A patient with a high "yellow flags" score is either experiencing abnormal illness behavior or is at risk for this. Management should be oriented toward reducing dependency on medication and other pas sive forms of treatment and encourage the develop ment of self-treatment skills. Such a patient is at increased risk for treatment failure with medica tion, manipulation, exercise, and surgery unless a biobehavorial approach is used. In certain cases, spe cialist referral for behavorial medicine counseling regarding affective and cognitive issues is required. It is important to realize that "yellow flags" are not the patient's fault, but they suggest management strategies need to be altered to maximize the likeli hood of recovery (see Chapters 14 and 31). Treatments incorporating cognitive-behavioral strategies have been shown to be effective for acute, subacute, and chronic patients (see Chapter 1) (44, 81). Chronically disabled workers have been shown to respond to a light multidisciplinary program that incorporated exercise, activity modification, and fear-avoidance beliefs advice (37,38,48,105). Work ers with poor prognoses because of the presence of substantial psychosocial "yellow flags" have responded to extensive multidisciplinary programs that incorporate a structured cognitive-behavioral approach (48,105). A mainstay of these approaches was that return to activity was quota-based, rather than being contingent on absence of symptoms. Such graded activity or "graded exposures" is per formed for a specific duration or frequency inde pendent of symptoms. Another aspect of successful programs is the emphasis on reduction of back-related worry. Re activation advice included reassurance regarding the safety of gradually resuming activities. These approaches de-emphasize labels suggesting a purely biomedical diagnosis such as herniated disc, arthri tis, or injury as the sole cause of pain.

J 96

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Patient Beliefs About the Nature and Treatment of Their Pain can Change with Cognitive-Behavioral Therapy

Audit Process


Patients w i t h c hronic L B P who bel ieved their pain was caused by structural pathology had more d i sabil i ty at basel i ne and demonstrated greater reductions in dis

What is the prognosis for acute low back pain becoming chronic?

•

What prognostic factors can be used to predi c t t h e r i s k o f acute back or n e c k pain becoming c h ronic?

abi l i lY after a cognitive-behavioral i ntervention. In a l l palients, a s biomedical/pathology beliefs were reduced, reported d i sab i l i ty also decreased. Walsh DA, Radcli ffe Je. Pain beliefs and perceived physical disability of patients with chronic low back pain. Pain 2002;

o

Symptom factors

o

Physical exa m ination factors

o

Psychosocial factors

o

Work-related factors

o

Functional factors

97:23-3 1 .

• CONCLUSION The acute phase of patient care is best served by a minimalist approach. Either excessive diagnostic testing or treatment can be iatrogenic (32). But waiting for pain to become chronic before institut ing more aggressive measures is also ineffectual because it is easier to prevent than to treat chronic pain. The key time frame for more focused aggres sive management is between 4 and 12 weeks. In particular, those with "yellow flags" should be more aggressively managed as early as possible. The I -month mark may appear to be a reasonable "deci sion point" for such evaluation (if it has not already occurred). The "yellow flags" screen is the ideal re-evaluation tool for a patient not recovering as well as hoped for. It adds little if anything to the cost of the re-evaluation modality of choice-advanced imaging (magnetic res onance imaging)-and is much more likely to reveal clinically useful information that can guide care (9). A positive "yellow flags" screen does not necessitate cognitive-behavioral therapy (87). But at a minimum, care must shift from primarily passive to active ap proaches. When these fail, then psychosocial coun seling, specifically cognitive-behavioral therapy, is indicated not necessarily because these issues caused acute pain, but because they are interfering with the normal recovery process (78). Framing patient care in this manner takes away the stigma associated with the determination that psychological factors are clin ically relevant. Pain is always a "mind-body" problem. Although physical factors may be involved in the condition's cause, once pain becomes persistent, frustration and even anger are normal reactions. Evaluating "yellow flags" is part of the biopsychosocial approach to man aging activity limiting disorders of the spine. It is easy to incorporate into management pathways and will allow customization of appropriate care to each indi vidual patient.

•

Have a few p at i ents fill out the "ye llow flags" questionnaire and score it.

•

o

Was i t a n administrative challenge?

o

Do certain items o n the questionnaire stand out?

Wou l d your "report of findings" be d i fferent for a patient w i t h a high level of fear-avoidance beliefs t ha n someone without these?

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1 04 . S h aw WS, Feuers t e i n M , H au n e r A J , Berkowi t z S M , Lopez M S . Work i n g w i t h l o w back pai n : Probl em-solving orientation a n d fu n c t i o n . P a i n 200 1 ; 9 3 : 1 29- 1 3 7 . 1 05 . Skouen J S , Grasdal A L , H aldorsen E M H , et a l . Rela t ive cost-effec t i veness o f extensive and l ig h t m u l t i d i s c i p l i nary treatment programs versus treat ment as usual for pat ients w i t h c h ronic low back pain o n long-term sick leave. Spine 2002 ; 2 7 : 90 1 -9 1 0. 1 06 . Sobel J B , Sol lenberger P, Robinson R, Pola t i n P B , Gatchel RJ . Cervical nonorganic signs: A new c l i n i cal tool to assess abnormal i l l ness behavior i n neck pai n patients: A plot study. Arch Phys Med Rehabi l 2000; 8 1 : 1 70- 1 7 5 . 1 07 . Spi tzer WO, L e B l a n c FE, D u p u i s M , et a l . Sci en t i fic approach to the assessment and management o f act ivi ty-related spi nal d i sorders: A m o nograph for c l i n i c ians. Report of t h e Quebec Task Force on Spinal D isorders. Spine 1 98 7 ; 1 2 ( suppl 7 ) : S l -S59. 1 08 . Swi n kels-Meewisse EJC M , Swi n kesl RAH M , Verbeek A L M , Vlaeyen JWS, Oostendorp RAB. Psychometric properties o f t he Tampa Scale for k i nesiophobia and the fear-avoidance bel iefs questionnaire for acute low back pai n . Man Ther 2003 ; 8 : 29-36. 1 09 . Takala EP, Vi kari -Juntura E. D o functional tests pre dict low back pai n . Spine 2000 ; 2 5 ( 1 6 ) : 2 1 26-2 1 32 . 1 1 0. Tenenbaum A, Rivano-Fischer M , Tjell C , Edblom M, Sunnerhagen KS. The Quebec Classification and a new Swed ish classification for whiplash-associated d i sorders i n relation to l i fe satisfaction i n patients at high risk o f c h ronic functional i m p a i rment and dis abi l i ty. J Reh a b i l Med 2002 ;34: 1 1 4- 1 1 8 . 1 1 1 . Teresi L M , Lufkin R B , Reicher MA, et a l . Asympto matic degenerative d isk d isease and spondylosis o f t h e cervical s p i ne : M R I m aging. Rad ioI 1 98 7 ; 1 64: 83-8 8 . 1 1 2 . Thomas E , S i l m an A J , C ro[1 P R , Papageorgiou AC, J ayson M IV, M acfarl ane G J . Predi c t i ng who devel ops c h ronic low back pain in pri m ary care: A prospect ive study. BMJ 1 999;3 1 8 : 1 662- 1 66 7 . 1 1 3 . Troup J D G . The perception o f pain and i ncapac i ty for work: Prevention and early treatment. Physio t her I 988;74:4 3 5 .

1 1 4 . Truchon M , F i l l ion L . Biopsychosocial determi nants of c h ro n i c d isab i l i ty and low-back pain: A review. J Occup Rehabil 2000; 1 0: 1 1 7- 1 42 . 1 1 5 . van den H oogen H J M , Koes BW, Devi l l e W , van E ij k J T M , Bouter L M . The prognosis of low back pain in general practice. Spine 1 99 7 ; 2 2 : 1 5 1 5- 1 5 2 t . 1 1 6 . Vlaeyen JWS, L i n ton S. Fear-avoidance and its con sequences in c h ronic m usculoskeletal pai n . A state o f the art . Pain 2000; 85 : 3 1 7-3 3 2 . 1 1 7 . V o n Korff M , Deyo R A , Cherkin D , Barlow W. Back pain in pri mary care: Outcomes at I year. Spine 1 99 3 ; 1 8 : 8 5 5-8 6 2 . 11 8 . Waddell G , McCul loch JA, K i m m e l E , Venner R M . Nonorganic p hysical s igns i n l o w back pa i n . Spine 1 980; 5 : 1 1 7- 1 2 5 . 1 1 9 . Waddell G , M o rris E W , D i Paola M P , B i c her M , F i n layson D A . Concept o f i l l ness tested a s an i m p roved bas i s for surgical dec i s i o n s in low back d i sorders. S p i ne 1 9 86; I I : 7 1 2-7 1 9 . 1 20 . Walsh D A , Radcli ffe J C . Pain bel i e fs and perceived physical d isab i l i ty of patients with chronic low back pai n . P a i n 2002 ; 9 7 : 2 3-3 1 . 1 2 1 . Weaver CS, Kvaal SA, McCracken L. Waddell signs as behavioral i n d icators o f depression and anxiety in c h ronic pai n . J Back M usculoskel Rehabil 2003/2004; 1 7 : 2 1 -2 6 . 1 2 2 . Wemeke MW, H arris EX, Di Paloa M P , Bicher M , F i n l ayson D. C l i n ical effec tiveness o f behavioral signs for scree n i n g chronic low-back pain pat ients i n a work-odented physical rehabil itation program. Spi ne 1 99 3 ; 1 8 : 2 4 1 2-24 1 8 . 1 2 3 . Werneke M , H art D L . Centra l i zation phenomenon as a prognostic factor for c h ronic low back pain and d i sab i l i ty. Spine 2 0 0 ] ; 2 6 : 758-765. 1 24 . Wiesel S E , Tsourmans N, Feffer H L, et a!. A study o f compu ter-assisted tomography. I . The i ncidence o f posi tive CAT scans in an asym ptomatic group of patients. Spine 1 984;9:549. 1 2 5 . Williams DA, Feuerstein M, Durbin D , Pezzulo J. Healt hcare and i ndem n i ty costs across the natural h istory o f disabi l i ty in occupat ional low back pai n . S p i ne 1 99 8 ; 2 3 : 2 3 2 9-2336.

I

I

Appendix 9A

YELLOW FLAG FORM

Name 1.

____

Primary complaint-

Please indicate your usual level of pain during the past week No pain o 1 2 3 4 5 6 7 8

_ _ _ _ _ _ _ _ _ _ _ _ _ _

9

Worst pain possible 10

2.

Does pain, numbness, tingling or weakness extend into your leg (from the low back) &/or arm (fTom the neck)? All of the time None of the time o 1 2 3 4 5 6 7 8 9 10

3.

How would you rate your general health? Poor o 1 2 3 4 5

( t o-x) 6

7

8

9

Excellent 10

4.

If you had to spend the rest of your life with your condition as it is right now, how would you feel about it? Delighted Terrible o 1 2 3 4 5 6 7 8 9 10

5.

How anxious (eg. tense, uptight, irritable, fearful, difficulty in concentrating / relaxing) you have been feeling during the past week: Not at all Extremely anxious o 1 2 3 4 5 6 7 8 9 10

6.

How much you have been able to control (i.e., reduce/help) your pain/complaint on your own during the past week: I can't reduce it at all I can reduce it o 1 2 3 4 5 6 7 8 9 10

7.

Please indicate how depressed (eg. Down-in-the-dumps, sad, downhearted, in low spirits, pessimistic, feelings of hopelessness) you have been feeling in the past week: Extremely depressed Not depressed at all o 1 2 3 4 5 6 7 8 9 10

8.

On a scale of 0 to 10, how certain are you that you will b e doing normal activities or working in six months? Very certain Not certain at all 3 4 0 1 2 8 10 5 7 9 6

9.

I can do light work for a n hour? Completely agree 4 0 1 2 3

5

6

7

8

9

Completely disagree 10

201

202

10.

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I can sleep at night Completely agree 2 o 1

3

4

5

8

7

6

] 1.

An increase in pain is an indication that I should stop what Completely disagree o 1 2 3 4 5 6 7

12.

Physical activity makes my pain worse? Completely disagree 3 4 5 1 2 o

13.

9

I should not do my normal activities including work with my present pain. Completely disagree o 1 2 3 4 5 6 7 8 9

Please sign your name

_______

SCORING

&

Completely disagree 10

am doing until the pain decreases. Completely agree 8 9 10

8

7

6

I

9

Date

Completely agree 10

Completely agree 10

_ _ _ _ _ _ _ _ _ _ _ _ _

RISK:

Low risk of chronic disability - under 55 points Moderate risk of chronic disability 55 to 65 points High risk of chronic pain and disability - over 65 points -

Evaluation of Muscular Imbalance

Vladimir Janda, Clare Frank, and Craig Liebenson

Introduction Evaluation of Tight Muscles Evaluation of Inhibited Muscles Analysis of Muscular Imbalance in Standing Gait Assessment Hypermobility

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Learning Objectives

After reading this chapter you should be able to understand: • • •

•

•

The etiology of muscle imbalance How to evaluate muscles for tightness or inhibition The interplay of different synergist and antagonist muscles during basic movement patterns How to evaluate posture for signs of muscle imbalance The basic elements of gait analysis

This chapter is dedicated to the memory of Pro Vladimir Janda (1928-2002) who passed away on November 25, 2002.

" ••• t) ••• 203

204

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Introduction

The primary basis of the functional approach to mus culoskeletal pain syndromes is the interdependence of all structures fTom both the central nervous and musculoskeletal system in the production and con trol of motion. Movement of non-contractile and con tractile elements is produced and controlled by muscle activity. Ultimately, it is the central nervous system in response to various stimuli that controls the activity of muscles and consequently, the pattern of motion in an individual's musculoskeletal system. The mus cular system lies at a functional crossroad because it is influenced by stimuli from both the central nervous system and musculoskeletal system. Dysfunction in any component of these systems is ultimately reflected in the muscular system in the form of altered muscle tone, muscle contraction, muscle balance, coordina tion, and performance. Therefore, a strictly localized lesion does not exist. Muscle imbalance is a systemic change in the quality of muscle dysfunction that results in altered joint mechanics leading to pain, dys f-unction, and eventually degeneration. Muscle imbal ance is the altered relationship and balance between muscles that are prone to inhibition or weakness and those that prone to tightness or shortness. Moderately tight muscles are usually stronger than normal. How ever, in the presence of pronounced tightness, some decrease of muscle strength occurs. This weakness is called "tightness weakness" (1) to express the closed association between muscle weakness and altered vis coelasticity of the muscle. Therefore, when diagnosing muscle weakness, careful differential diagnoses have to be made. The treatment of tightness weakness is not in strengthening, which would increase tightness and possibly result in a more pronounced weakness, but in stretching, oriented toward influencing the visco elastic property of the muscle, i.e., the noncontractile but retractile connective tissue. Stretching of tight muscles also results in improved strength of inhib ited antagonistic muscles, probably mediated via Sherrington's law of reciprocal innervation. The etiology and terminology of muscle tone is full of controversies, partly because various authors' def initions of muscle tone differ. Therefore, a detailed differential diagnosis has to be made among others because each condition requires a different type of treatment (2). Unfortunately, a precise and adequate analysis is often neglected. An imprecise diagnosis results in disappointing therapeutic results. Unfor tunately, the detailed physiology of muscle tone is unknown and studies of muscle tone changes caused by altered or impaired function have not been studied sufficiently in the laboratory or in the clinic. In principle it is necessary to differentiate whether the main changes occur in the connective tissue of the muscle (viscoelastic properties) or in over-activation

of the contractile components of the muscle (con tractile properties). According to Mense and Simons, "Muscle tension depends physiologically on 2 factors: the basic viscoelastic properties of the soft tissues associated with the muscle, and/or the degree of acti vation the contractile apparatus of the muscle" (9). In the former, we speak about muscle tightness, stiff ness, loss of flexibility, or extensibility (length), and in the latter, it is a real increase of muscle contractile activity such as in spasmodic torticollis or trismus. In principle, with respect to viscoelastic changes, the muscle gets shorter at rest (decreased extensibility), either because of shortening of contractile muscle fibers or because of retraction of the connective tis sue within the muscle and the adjacent fascia. With respect to contractile changes, the increased muscle tone may involve the majority of muscle fibers of the muscles or only a limited number as found as "taut bands" in trigger points. Clinically, resting muscle tone presents a combi nation of both situations (contractile and viscoelastic properties), and it is the role of the clinician to estab lish an appropriate diagnosis (9). However, measur ing muscle tone objectively presents a dilemma. Tests of viscoelasticity involve measurements of the veloc ity of motion, viscosity, thixotropy, and resonant fre quency when load is gradually applied (9). Tests of contractile activity are simpler in that EMG can be used; however, this is not without inherent difficul ties, as in trigger points where only small loci in the muscle show increased electrical activity (9). A detailed differential diagnosis of muscle tone is necessary for the proper treatment approach, and this can be accomplished by a combination of inspection and palpation (Table 10.1). Layer palpation of the skin, subcutaneous tissue, fascia, fat, and any other struc ture in the area concerned, although purely subjective is a practical clinical tool and with much practice and experience, detecting the type of muscle tone pre sent in the concerned area can be skillfully achieved. Inspection of posture, movement patterns, and gait also yields invaluable clinical information about the underlying source of increased muscle tension. Muscle imbalance should be considered a systemic reaction of the striated muscles. It is therefore a gen eral reaction of the whole muscle system and not just an isolated response of an individual muscle (4). This view is strongly supported by the recent findings of neurodevelopmental kinesiology, which show devel opmental movement patterns corresponding to the muscle imbalance found in children when their motor system is fully myelinized (at the age of 6 to 7 years) or in adults (7,8,12). The basis from a neurodevelop mental viewpoint is that neonatal and early infant posture is maintained by a "tonic" muscle system. Subsequent neurodevelopment of the upright pos-

Chapter Ten: Evaluation of Muscular Imbalance

Table 10.1

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205

Functional Types of Muscular Hypertonicity (from Janda) (2)

Types

Limbic Segmental Reflex "spasm"

Anatomically

Spontaneously

Distributed1'

Painful1d'

Other Signs

no yes not always

no yes yes i E.M.G. at rest part of active TP-yes muscle latent TP-no

stress i.e., tension headache antagonist weak, pain[-ul to stretch :Defense Musculare" i.e. wry neck

Trigger Points (partial "muscle spasm") yes

Muscle Tightness

no

parts of muscle hyperilTitable, neighboring muscle fibers inhibited i irritability, J- extensibility

*Anatomically distributed hypertonicity is present in specific anatomically defined muscles and not in parts of different muscles in the same area. *" Spontaneously painful a muscle is a source of pain at rest and not merely painful on palpation. Reproduced with permission from Liebenson CS. Active Muscular Relaxation Techniques, Part One: Basic Principles and Methods. J Manipulative Physiol Ther 1 989; 12:6 (Table 2). =

=

ture occurs with the co-activation of a "phasic" mus cle system with the "tonic" muscle system. Failure of this co-activation between the tonic and phasic mus cle system results in a muscle imbalance and is clearly evident in children with cerebral palsy in which the "tonic" muscle system prevails. In addition, the typi cal muscle responses seen in chronic low back pa tients are observed to be identical or very similar to those that are seen in some structural lesions of the central nervous system. For example, in spasticity seen in a cerebrovascular accident or cerebral palsy, muscles that develop spasticity or even spastic con tractures are those that commonly respond by tight ness in musculoskeletal conditions. It is proposed that these typical muscle responses observed in the typical hemiplegic posture may be an extreme expres sion of the imbalance between the muscular chains that exist to some extent under normal physiologic conditions. Thus, the tendency for some muscles to develop weakness or tightness does not occur ran domly but rather in typical "muscle imbalance pat terns" (3). Furthermore, the development of these patterns can be predicted clinically and preventative measures should be taken because muscle imbalance does not remain limited to a certain part of the body, but gradually involves the whole striated muscular sys tem (6). A thorough evaluation is necessary to intro duce preventive measures because muscle imbalance usually precedes the appearance of pain syndromes. Muscle imbalance develops mainly between pre dominantly "tonic" muscles, that is, muscles that are prone to develop tightness and predominantly "pha sic" muscles, that is, muscles that are prone to develop inhibition (Table 10.2). Muscle imbalance involves

muscles of the whole body; however, if the imbalance is more evident or starts to develop gradually and pre dictably in the pelvic region, we speak about the pelvic or distal crossed syndrome, and i fit is more evident or starts in the shoulder girdle/neck region, we term it as a proximal or shoulder girdle crossed syndrome (5). The proximal ( upper, shoulder-neck) crossed syn drome is characterized by the development of tight ness in the upper trapezius, levator scapulae, and pectoralis major, and inhibition in the deep neck flexors and lower stabilizers of the scapula. Topo graphically, when the inhibited and tight muscles are connected, they form a cross (Fig. 10.1). This pattern of muscle imbalance produces typical changes in pos ture and motion. In standing, elevation and protrac tion of the shoulders are evident, as are also rotation and abduction of the scapula, a variable degree of winging, and a push-forward head position. This altered posture is likely to stress the cervicocranial and the cervicothoracic junctions. In addition, the stability of the shoulder blades is decreased, because of the altered angle of the glenoid fossa, and, as a con sequence, all movement patterns of the upper extrem ity are altered. The distal (lower, hip-pelvic) crossed syndrome is characterized by tightness of the hip flexors and spinal erectors and inhibition and weakness of the gluteal and abdominal muscles. As in the upper crossed syn drome, a line connecting the tight and inhibited mus cles forms a cross (Fig. 10.2). This imbalance results in an anterior tilt of the pelvis, increased flexion of the hips, and a compensatory hyperlordosis in the lum bar spine. This imbalance tends to over-stress both hip joints as well as the lower back.

206

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Table 10.2

Muscle 1mbalances

Muscle that have a tendency to develop: Tightness/Shortness

WeaknesslInhibition

Gastrocsoleus Hip flexors Rectus femori Iliopsoas Tensor fascia lata Adductors Hamstrings Erector spinae Quadratus lumborum Piriformis Upper trapezius/levator scapulae Pectorals Sternocleidomastoid Shorl deep cervical extensors Upper extremity flexors

Tibialis anterior Vasti (in particular, the vastus medialis obliquus) Gluteus maximus Gluteus medius and minimus Abdominal wall Lower and middle trapezius Serratus anterior Deep neck flexors (longus colli and capitis) Scalenes Upper extremity extensors

A combination of these two syndromes is expressed in a layer (stratification) syndrome (Fig. 10.3). When a layer syndrome is observed in a patient, it is a sign of a poorer prognosis in terms of rehabilitation because of the fixed muscle imbalance patterns at the central nervous system level. Examination of joints must precede muscle eval uation of muscles to exclude any anatomical batTier. In clinical practice, it is advisable to begin muscle

Erector Spinae

�

, I , , , , I ,

Gluteus Maximus

Iliopsoas

Tight Weak Deep Neck Flexors

Abdominals

Weak

Of

Inhibited

Tight Upper Trapezius and Levator Scapula

Weak or Inhibited

Tight Pectorals

Weak Lower Trapezius and Serratus Anterior

Figure

10.1 Upper crossed syndro me.

Figure 10.2 Lower crossed syndrome.

Tight


Muscle Hypotrophy

--

207

Muscle Hypertrophy

Cervical Erector Spinae Upper Trapezius Levator Scapulae Lower Stabilizers of the Scapula Thoracolumbar Erector Spinae Lumbosacral Erector Spinae Gluteus Maximus

Hamstrings

Quadratus Plantae

Figure

10.3 Layer (stratincation) syndrome.

evaluation by analyzing erect standing posture and gait. This analysis requires experience and keen obser vational skill. In addition, it serves as a screening tool by providing quick and reliable information to direct the clinician the necessary tests that need to be per rormed in detail and those that can be omitted. The c1inician is given an overall view of the patient's mus cle function through posture and gait analysis and is challenged to look comprehensively at the patient's entire motor system and not to limit attention to the local level of the lesion. Evaluation of muscle imbalance in a patient with an acute pain syndrome, however, is unreliable and must be undertaken with precaution. A precise evaluation of tight muscles and movement patterns can be performed only if the pa tient is pain-free or almost pain-free. Its usefulness is greatest in the chronic phase or in patients with recur rent pain after the acute episode has subsided.

Figure

10.4 Upper trapezius.

when the movement is restricted, the barrier has an abrupt firm to hard end-reel. Levator scapulae (Fig. 10.5) is examined in a sim ilar manner, except that the head is also rotated to the contralateral side. Pectoralis major (Fig. 10.6) is tested with the pa tient supine. The trunk must be stabilized before the arm is placed into abduction because a possible twist of the trunk might mimic the normal range of move ment. The arm should reach the horizontal level. To estimate the clavicular portion, the arm is allowed to hang down loosely and the examiner applies a poste rior glide to the shoulder. Normally, only a slight soft barrier is felt. Deep posterior neck muscles can be tested only by thorough palpation. Evaluation of the sternocleido mastoid is not reliable because it crosses too many segments (Fig. 10.7).

Evaluation Of Tight Muscles

Upper trapezius (Fig. lOA) is tested with the patient supine, with the head passively flexed and side-bent to the contralateral side. Once the slack is taken up, the shoulder girdle is pushed distally. Normally, a sort barrier is felt at the end of the push; however,

Figure 10.5 Levator scapulae.

208

--


Figure

10.6 Pectoralis major.

Hip flexors ( iliopsoas [Fig. 10.8] and rectus femoris [Fig. ] 0.9]) are lested wilh the patient in a modified Thomas position. The presented modification also allows for a screening examination of the short lhigh adductors and the tensor fascia lalae. The patienl is supine wilh the torso on the plinth and the lested leg loosely hanging. The non-lesled leg is maximally flexed lo stabilize the pelvis and flat len the lumbar spine. A flexed posilion of the hip joint indicates lightness of the iliopsoas, whereas the oblique posilion of the lower leg indicales tighlness of the rectus. The inability to achieve passive hyperex tension in the hip joint and passive full flexion of lhe

knee ( 135 degrees) confirms the tightness of the iliop soas and the rectus, respeclively. Limitation of passive hip adduction to 15 degrees or less indicates the tight ness of the tensor fascia lala ( Fig. 10. 10); abduction less than 25 degrees indicates shortness of the one joint thigh adductors. This lest can be influenced by lhe stretch of the joinl capsule and lhus more specific test should be performed to confirm the lightness of the adductors ( Fig. 10.11). Confirmation of tightness is clear when excessive soft tissue resistance and decreased range of motion are encountered on applicalion of pressure in the fol lowing direclions:

Figure 10.7 Screening test fOI- sternocleidomastoid tightness.


Figure

•

•

•

--

209

10.8 Iliopsoas.

Hip extension less than 10 to 15 degrees iliopsoas. A simultaneous extension of the knee joint points to the shortening of the rectus femoris. Knee nexion less than 100 to 105 degrees rectus femoris. Compensatory hip flexion may occur during the test. H ip adduction less than 15 to 20 degrees tensor fascia lata and the iliotibial band. An

Figure

10.9 Rectus femoris.

associated deepening of the groove on the outside of the thigh is also noted In the presence of tightness. •

Hip abduction less than 15 to 20 degrees short hip adductors. The tendency toward compensatory hip flexion should be controlled during the test.

Hamstrings ( Fig. 10. 1 2) tightness is evaluated by the straight leg raise test. To avoid the influence of

2J a

--


Figure

10.10 A screening lesl for lensor fascia

lala lightness.

tight iliopsoas on the position of the pelvis and consequently on the range of hip flexion, the non tested leg should be in placed in flexion. Under these circumstances, the normal range of motion is 90 degrees. Thigh adductors are tested with the patient lying supine at the edge of the plinth (Fig. 10.13). The passive abduction in the hip joint should be at least 45 degrees. Tight hamstrings may contribute to the range limitation. If this situ ation occurs, bending the knee should increase the range or movement.

The piriformis muscle is tested with the patient in a supine position. The tested leg is placed with the hip joint in flexion not more than 60 degrees and in maximal adduction. The pelvis is stabilized by apply ing a force on the hip through the long axis of the femur (Fig. 10.14). Then, the adduction and internal rotation of the hip is performed. Normally, a soft, gradually increasing resistance is noted at the end of the range of motion. If the muscle is tight, the end feel is hard and may be associated with pain deep in the buttocks.

Figure

10. 1 1 Screening lest for the short hip

adduclors.


Figure 10.12 Hamstrings.

Figure 10.13 Thigh adductors (A); test if ham strings are tight (B).

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211

Quadratus lumborum is difficult to examine be cause this muscle spans m any spinal segments. In principle, passive trunk side bending is lested while the patient assumes a side-lying position (Fig. 10. 15). The reference point is the level of the inferior angle of the scapula, which should be raised approximalely 2 inches from the floor. A simpler screening lesl entails observation of the spinal curve during active lateral flexion of the trunk. Spinal erectors are also difficult to examine for lhe same reason as the quadratus lumborum. As a screen ing test, forward bending in a short sit allows obser vation of the gradual curvature of the spine ( Fig. 10. 16). A more reliable test, however, is the dual inclinometer test for lumbar flexion mobility shown in Chapter 1 2. Triceps surae are tested by performing passive dorsiflexion of the foot. Normally, the therapist should

212

--


Figure 10.14 Screening test for piriformis tight ness (A); palpation test for piriformis tension or irritability (B).

be able to achieve passive dorsiflexion to 90 degrees (Figs. 10.17 and 10. ] 8). More detailed description of the tests is available elsewhere (3).

Evaluation Of Inhibited Muscles

Classic muscle strength testing involves resistance or a m ovement in the direction characteristic for the specific muscle or muscle groups being tested. The production of a m ovement is in actuality, a series of muscles acting as prime m overs, synergists, or stabilizers that combine together to produce a m ovement (3). Therefore, classic m uscle strength testing does not provide su fficient nor reliable infor-

m ation. The quality of performance of the m ove m ent is of greater importance than the test for strength. This type of evaluation is less focused on the strength of the particular movement, but more focused on the sequencing and degree of activation of the prime m overs and their synergists. In this respect, the initiation of the movement is more important than the end of the m ovement. Poor qual ity and control of movement can produce and/or perpetuate adverse stresses on joints and muscle m echanics. Although m ovement patterns are indi vidualized, the typical normal and abnormal pat terns can be recognized. In principle, six basic movement patterns provide overall information about the movement quality of the particular subject: hip (hyper)extension, hip


Figure 10.15 Screening test for quadratus lumborum tightness.

Figure

10.16 Screening test for erector spinae

tightness.

Figure 10.17 Gastrocnemius.

--

213

2J4

--


Figure 10.18 Soleus.

abduction, curl up, push up, neck flexion, and shoul der abduction. During movement pattern testing, minimal verbal cues should be used which test an individual's habitual way of performing a movemenl. If the cues are too "leading," then the test will be of the subject's ability to learn how to perform the move ment correctly, rather than how the subject is habit ually performing it. The hip (hyper)extension movement test (Fig. 10.19) is examined to analyze one of the most important phases of the gait cycle-i.e., hyperextension of the hip at the terminal stance phase of gait (10,11). This test is performed with the patient lying prone. During straight leg lifting into extension, the sequencing and degree or activation of the h amstrings, gluteus maximus, spinal extensors, and shoulder girdle mus cles are observed. The first sign of altered pattern is when the hamstrings and erector spinae are readily activated during the movement, whereas contraction of the gluteus maximus is delayed, decreased, or absent. The poorest pattern occurs when the erector spinae on the ipsilateral side or even the shoulder gir dle muscles initiate the movement and activation of the gluteus maximus is weak and substantially delayed. In this situation, the entire motor perfor mance is ch anged. Little if any extension in the hip

Figure 10.19 Hip extension.

joint is noted and the leg lift is achieved through pelvic anterior tilt resulting in hyperlordosis of the lumbar spine, which undoubtedly over-stresses this region. Knee flexion should be noted because it indi cates the hamstrings are predominating over the glu teus maximus. Hip abduction (Fig. 10.20) gives information about the quality of the lateral muscular pelvic brace and thus indirectly about the stabilization of the pelvis in walking. It is tested with the patient in the side-lying position. The gluteus medius and minimus together with the tensor fascia lata act as prime movers while the quadratus lumborum acts as a pelvic stabilizer. The first sign of an altered abduction pattern is a ten sor mechanism of hip abduction, when compensatory hip flexion is observed instead of pure abduction The poorest pattern of hip abduction occurs when the quadratus lumborum, in addition to stabilizing the pelvis, initiates the movement through elevation of the pelvis. This altered pattern can cause excessive stress to the lumbar and lumbosacral segments dur ing walking. Trunk curl-up (Fig. 10.21) is tested to estimate the interplay between the usually strong iliopsoas and the abdominal muscles. Initially, the examiner observes the patient's spontaneous pattern of sitting


--

215

Figure 10.20 Hip abduction.

Figure 10.21 Trunk curl-up.

up. In the presence of weak abdominals and strong dominant iliopsoas, the curling movement of the trunk is minimal and the movement will be per formed with an almost straight back and anterior tilting of the pelvis. The movement is thus per formed mostly in the hip joint rather than by kypho sis of the trunk. Another way to detect if the iliopsoas is the dominant mover during the curl-up is [or the

clinician to place his hands under the patient's heels. The iliopsoas is predominant over the abdominals when the pressure o[ the patient's heels on the clin ician's hands is lost. Push-up (Fig. 10.22) [Tom the prone position pro vides information about the quality of the stabilization of the scapula. During the push-up, and particularly in the beginning phase of lowering the body from

Figure 10.22 Push-up.

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maximum push-up, excessive scapular rotation, ele vation, adduction, or abduction are noted. The type of motion depends on what muscles are dominant. If lev ator scapulae are dominant, then one might see an elevation and downward rotation of the scapulae. If the serratus anterior is not functioning adequately, winging of the scapula will be observed. Head Oexion (Fig. 10.23) provides information about the interplay between the sternocleidomas toideus and the deep neck flexors. This information is essential in estimating the dynamics of the cervi cal spine and is tested with the patient supine. The subject is asked to raise the head slowly in the habit ual way. When the deep neck flexors are inhibited and the sternocleidomastoideus is overactive, the jaw juts forward at the beginning of the movement with hyperextension in the cervicocranial junction. If the pattern is u nclear, slight resistance of approxi mately one to two finger weights against the forehead may be applied. This slight resistance may exaggerate the hyperextension even more, indicating a weakness of the deep neck flexors. Shoulder abduction (Fig. 10.24) provides infor mation about the coordination of muscles of the shoulder girdle. It is tested while the patient is sitting, with the elbow flexed to control u ndesired rotation.

Clinical Pearl

o

Figure 10.23 Head flexion "correct"

(A) and "incorrect" (B).

Stretch Before Strengthening

If a movement pattern is faulty, the general rule of

thumb is to initiate rehabilitation by treating tight mus cles related to the faulty pattern. Once tight muscles are addressed then facilitation and training of the "weak link" can proceed. The reason for this is if muscle tight ness is present, then strength training will typically re inforce "trick" movements, thus perpetuating the muscle incoordination. For instance, if the trunk curl-up test is positive, then treatment com mences with releasing the iliopsoas first and then com mencing an abdominal training program. With the tight hip flexors relaxed and lengthened, abdominal training will proceed with less joint stress and easier isolation of the target muscles. The exception to this general rule of stretching tight mus cles before strengthening "weak" muscles is if length test ing shows that the iliopsoas is not actually tight. In this case, facilitation of the inhibited muscle can begin right away. However, because the movement pattern is faulty, a training position and range must be found that allow isolation of the agonist muscle without excessive substi tution of synergist or antagonist muscles.

Shoulder abduction is a result of three components: abduction in the glenohumeral joint, rotation of the scapula, and elevation of the shoulder girdle. Move ment is stopped at the point at which shoulder girdle elevation commences. This usually occurs at approx imately 60 degrees of abduction at the glenohumeral joint. In an individual with shoulder dysfunction, shoulder girdle elevation starts earlier or may even initiate the movement.

Analysis Of Muscular Imbalance in Standing

In an analysis of standing, an attempt is made to differentiate between possible provocative causes, including structural variations, age, altered joint mechanics, and residual effects of pathologic pro cesses. In this chapter, only muscular changes are described, although all biomechanical deviations, such as scoliosis, leg length difference, and all other


Figure 10.24 Shoulder abduction "correct"

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(A) and "incorrect" (B).

orthopedic deviations are taken into consideration. In muscular analysis, the main concern is with size, shape, and tone of the superficial muscles known to react by hyperactivity and tightness or by weakness and inhibition. The role of deeper muscles may need to be confirmed or negated in subsequent muscle length tests. The patient is first observed [Tom behind and an overall impression of posture is determined. Atten tion is then directed toward the position of the pelvis, because abnormalities of other structures such as the lumbar spine, sacroiliac joints, and lower limbs are, as a rule, reflected in the pelvis. An increase or decrease in sagittal tilt (posterior or anterior pelvic tilt), a lateral shift, an oblique position (pelvic un-leveling), rotation (transverse plane), and torsion (multiplanar distor tion) should be noted. The pelvic crossed syndrome may be responsible for the increased anterior tilt of the pelvis. This condition is usually associated with increased lumbar lordosis. The pelvic rotation is usu ally associated with shortness of the piriformis and/or iliopsoas; an oblique position of the pelvis is associ ated mostly with leg length asymmetry. Tightness of thigh adductors, quadratus lumborum, and iliopsoas tend to shorten the leg, whereas tightness of the pir iformis tends to lengthen the leg. Next, the shape, size, and tone of the buttock are observed. Observation of the gluteus maximus is

directed to the upper half of the muscle where con tour and tone is noted. The general appearance of the gluteus, whether one is bulkier or sagging, gives the clinician a clue on the motor [unction of the muscle. Usually, the gluteus is hypotonic and inhibited on the side where the sacroiliac joint is blocked. The ham strings are usually well developed, but it is important to look at their bulk relative to that of the glutei, because when the latter is inhibited, the hamstrings often become predominant. This change is readily evident if the impairment is unilateral. The shape of the line of the medial aspect of the thigh gives important information about the thigh adductors. In individuals with adductor tightness, the one-joint adductors form a distinct bulk in the upper one third of the thigh. The one-joint adductors are, as a rule, short and tender on palpation in patients with pain ful hip joint afflictions. On the calf, differentiation must be made between the gastrocnemius and the soleus. If the whole triceps surae is short, the Achilles tendon seems broader, and if the soleus is tight, in addition, the lower leg becomes cylindrical (Fig. 10.25). Careful examination of the back muscles is war ranted. The bulk of the erector spinae should be com pared from side to side, as well as [Tom the lumbar to the thoracolumbar region. There should be no evident difference between sides and regions. Prevalence or

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hypertrophy of the thoracolumbar spinal erectors may be indicative of poor muscle stabilization in the lumbosacral region (Fig. 10.26). The interscapular space and the position of the shoulder blades give information about the quality of the lower stabilizers of the scapula. If these muscles are weak and/or inhibited, slight abduc tion, elevation, and winging of the shoulder blade are observed (Fig. 10.27). Tightness of the upper trapezius and levator scapulae (Fig. 10.28) can be seen on the neck shoulder line. In areas of tightness, the contour straightens. If tightness of the levator predominates, the contour of the neckline appears as a double wave in the area of insertion of the muscle on the scapula. This straightening of the neck shoul der line is sometimes described as a "Gothic shoul der" in that it is reminiscent of the form of Gothic church windows. Viewing the patient from the front, the quality of the abdominals is observed first. Ideally, the abdom inal wall is flat. A sagging and protruded abdomen may reflect generalized weakness of the abdominals. When the obliques are dominant, a distinct groove is apparent on the lateral side of the recti. This finding indicates a possible decrease in the stabilizing func-

Figure 10.25 Soleus lightness on the right.

Figure 10.26 Right t horacolumbar erector spinae

hypenrophy.

tion of the abdominal wall in the anteroposterior direction, an important factor for stabilization of the spine (Fig. 10.29). The two anterior thigh muscles that can influence the lumbopelvic posture are the tensor fasciae lata and the rectus femoris. Normally, the bulk of the tensor is not distinct. Its visibility, coupled with the appearance of a groove on the lateral side of the thigh, usually indicates that this muscle is overused and short. When the rectus femoris is tight, the position of the patella shifts slightly upward and also later ally in the case of concurrent lightness of the ili otibial tract. Tightness of the pectoralis major is characterized by a more prominent muscle belly and thickness of the anterior axillary fold. Typical imbalance will lead to rounded and protracted shoulders. Much information can be obtained from observation of the anterior aspect of the neck and throat. Normally, the sternocleido mastoid muscle is just slightly visible. Prominence of the insertion of the muscle, particularly its clavicular (proximal) portion, is a sign of tightness. A groove along this muscle is an early sign of weakness of the deep neck flexors. Straightening of the throat line (this is the angle made between the chin and throat line-


Figure 10.27 Abduction and winging of the right scapula.

Figure 10.28 Tightness of the levator scapulae.

Figure 10.29 Oblique abdominal dominance.

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normal is usually approximately 90 degrees) is usually a sign of increased tone of the suprahyoid muscles, which may be the underlying cause of a temporo mandibular joint dysfunction. Palpation of the supra hyoids often reveals trigger points. Additionally, head posture should be observed. From a muscular point of view, a forward head posture is linked to weakness of the deep neck flexors and dominance or even tight ness of the sternocleidomastoid. From this brief description, it is evident that neg lecting the analysis of the muscular system in standing leads to a loss of a substantial amount of informa tion. Only the main changes or most frequent find ings are mentioned in this chapter; however, other less common or subtle signs will provide additional valuable information. Gait Assessment

Gait is the most automatized movement. The basic gait reflexes are regulated on a spinal cord level; however, the more complex reflexes are regulated on the subcortical or even cortical level. The variety of the gait patterns is remarkable. In fact, there are no two people on the world who would have the same gait. This fact has lead to a proposal to use the gait pattern to identify individuals in criminology. The gait pattern is so deeply fixed that it can be changed only with greatest difficulties, if at all. Thus the individual subject maintains his/her gait pattern during the whole adult lifetime. Only a severe injury that requires adaptation of the whole motor system results into changes of the gait pattern, although even in this case some basic qualities will remain unchanged. For these reasons it is very difficult, if not impos sible, to estimate norms. Therefore, statistical data regarding gait are of a very limited value in the clin ics and for an individual patient. Despite all these dif ficulties and diagnostic limitations, the visual gait analysis is of a paramount importance as it provides important information about possible over-stresses of critical segments of the human body in the indi vidual patient. In addition, skilled observation of gait helps the clinician toward a more detailed diagnosis and rational of treatment. In principle, two general types of gait can be recog nized:

The proximal type: The body is propelled forward mainly by pronounced hip and knee flexion, followed by hip extension beyond the midline. The center of gravity remains relatively level with minimal stress on the ankle joints and possibly greater over-stress on the hip joint.

Figure 10.30 One-leg standing test. (A) Normal one-leg stance, pelvis and shoulders level, minimum of lateral pelvic shift. (B) Positive Trendelenburg sign. Lateral shift and oblique position of the pelvis, contralateral shoulders elevated.


In the distal type, the body is propelled forward virtually by plantar flexion of the feet with minimal motion at the hip and knee j oint. The center of gravity is elevated with each step. This type of gait i s seen as "bouncy" or sim ilar to gait bserved i n children with muscular dystrophy who walk on their toes. After estimating the type of gait, length, and sym metry of the length of the step, the m ovem ents of the pelvis are observed. There are five basic move ments that we should look at: 1.) anterior and 2.) pos terior pelvic tilt in the sagittal plane, 3.) lateral and oblique shift, 4.) pelvic rotation, and 5.) the "butter fly " movement of the pelvis, which is an "openin�" and "closing" of the pelvis as a result of m ovement m the sacroiliac joint. Anterior pelvic tilt has to be correlated with the lumbar lordosis and thus stability of the whole torso. The easiest way to estimate this clinically is to compare the position of the pelvis with the position of the shoulders. If the trunk stability is good, the whole body-particularly in two critical areas, the pelvis and shoulders-will m ove forward in one line. If trunk stability is i nsufficient, the shoulder move ments will lag behind. Pelvic movements are associ ated with the range of hip extension and lateral muscular pelvic brace, which is important during one leg stance. It has to be noted that approximately 85% of gait cycle involves standing on one leg A quick test to check on the lateral brace is to have the patient perform a single leg stance with his eyes open ( Fig. 10.30). The clinician observes for the amount of pre-shift to the stance leg and un-leveling of the pelvis and/or shoulders. The normal pre-shift to the stance leg should not be m ore than 1 inch and the patient should be able to perform the single leg stance [or approximately 15 seconds without any com pensatory m ovements. Arm movements during gait are another source of valuable information. Sym m etry of arm m ove ments is observed, with particular attenti on to whether the movement is predominantly initiated by movement in the shoulders ( which is ideal), or by a pronounced elbow flexion. The third type of arm m ovement observed is m ovement initiated predom inantly by rotation of the trunk. The latter is often the result of increased stresses on the whole spine.

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Clinical Pearl Differentiating Muscle Weakness from Inhibition for the Gluteus Maximus

M uscle strengthening programs are often time-consu m ing. In many instances of supposed muscle weakness, detailed analysis reveals that the muscle is not actually weak, but only inhibited. In such cases the correct man agement is facilitation, not strength training. Identifying the specific nature of the muscle dysfunction is a "time saver" in the clinic. H i p Extension/G luteus Maximus

The b crluteus maximus is an important hyper-extensor of the hip. The hip (hyper)extension test is a simple screen showing the interplay of gluteus maximus, hamstrings, erector spinae, and hip flexor muscles. The i mportance of this movement is that it is an essential phase of the gait cycle. Neither faulty gait during "toe off" nor a faulty hip extension movement pallern tells us if the gluteus max imus is weak or inhibited. However, a simple test involv ing backward walking will make this differentiation. During backward walking, the gluteus maximus is nor mally facilitated. Thus, incoordinated backward walking as evidenced by increased lumbar lordosis or an anterior pelvic tilt indicates that the gluteus maximus is twly weak and not merely inhibited. This is particularly stri king i f the dysfunc tion i s unilateral. This suggests that longer term training will be required to improve function. In contrast, an improved lumbo-pelvic posture during back ward walking in comparison to standing posture, forward walking, or during the prone hip (hyper)extension test suggests that the gluteus maximus is only inhibited and probably can be trained easily. If inhibition is present, treat ment may involve post isometric relaxation ( PI R ), facilitation ( PNF diagonals, Sister Kenny methods), or joint man ipulation. I f weak ness is present, then progl-essive resistance training (e.g., bridges, squats, lunges, and single leg reaches) will also be required. A goal-oriented continuum of care might look like this:

Continuum of Care •

Inhibit-hip flexors

•

Facilitate-gluteus maximus

•

Mobilize-lower quarter and lumbo-pelvic joints

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Clinical Pearl Differentiating Muscle Weakness from Inhibition for the Gluteus Medius

The gl uteus medius is the most important lateral stabi lizer of the hip and pelvis. During gait an insufficiency of the lateral brace on the stance leg will lead to pelvic un-leveling (i.e., Trendelenburg) and difllculty achieving clearance of the toes from the ground on the contralateral swing leg. The person may not trip, but an uneconom ical gait wil l result. The hip abduction test is a simple screen showing the interplay of gluteus medius, tensor fascia lata, quadratus lumborum, and hip adductors. Unfortu nately, neither pelvic un-leveling du.-ing gait nor a faulty hip abduction movement pattern w i ll tel l us if the glu teus medius is weak or only inhibited. However, a sim ple test involving walking while holding a light object in the hands overhead w i l l make this differentiation. During this test the gluteus medius is normally facili tated. Thus, incoordination as evidenced by increased lateral sway 01- pelvic un-leveling indicates muscle weak ness not inhibition is involved. This is most notable if the dysfunction is unilateral. In contrast, an improvement in lateral pelvic stability or pelvic obliquity when compared to normal walking or standing posture suggests gluteus medius inhibition not weakness is present. If weakness is present, then progressive resistance train ing (clam shell, single leg bridge, wall ball , and single leg reaches) will also be requil-ed. A goal-oriented continuum of care m ight look like this:

Continuum of Care •

Constitutional h ypermobility involves the entire body, although all areas may not be affected to the same extent and slight asymmetry can be observed. This syndrome is noted more frequently in women and it typically involves the upper part of the body. With aging, h ypermobility decreases . Patients with constitutional hypermobility may develop muscle tightness as well, although it is never so evident. Mostly, this tightness is considered a compensatory mechanism to stabilize, in particular, the weight bearing joints. Therefore, stretc hing, if necessary, should be performed gently and only in key muscles that are supposed to be decisive in a particular syn drome. Because the muscles generally are weak, they may be easily overused and, therefore, trigger points in muscles and ligaments develop easily. There is no effective treatment of the syndrome of consti tutional hypermobility. However, reasonably pro longed strengthening and sensorimotor programs are usually helpful. Assessment of hypermobility is in principle based on estimation of muscle tone by palpation and range of motion of the joints. In clinical practice, orien tation tests usually are sufficient. I n the upper part of the body, the most usef-ul tests are head rotation high arm cross (Fig. 1 0.3 1 ), touching the hand� behind the n eck (Fig. 10.32), extension of the el bows ( Fig. 10.33), and h yperextension of the thumb (Fig. 10.34). In the lower part of the body, the best choices are the forward bending test (Fig. 10.35), lateral flex ion test, leg raising test, and dorsiflexion of the foot (Fig. 10.36).

Inhibit-adductors, Piriformis, TFL, quadratus lumborum, psoas

•

Facilitate-g luteus medi us

•

Mobilize-lower quarter and lumbo-pelvic joints

Hypermobility

M uscles can be involved in many other afflictions. One of the most common situations is constitutional hypermobility. This vague non-progressive clinical syndrome of unknown origin is not really a disease. It is ch aracterized by a general laxity of connective tis sues, muscles, and, in particular, ligaments. Muscle strength in affected individuals usually is low, and even a vigorous strengthening exercise does not lead to evident hypertrophy. The muscle tone is decreased when assessed by palpation and the range of move ment in joints is comparatively increased. Despite joint instability, it h as not been confirmed that "hyper mobile" subjects are more prone to musculoskeletal pain syndromes.

Figure 10.31 High arm cross.


Figure 10.32 Touching the hands behind the neck.

Figure 10.34 Hyperextension of the thumb.

Figure 10.33 Extension of the elbows.

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Figure 10.35 The fon.vard bending lest.

Figure 10.36 Dorsiflexion of the foot.


• CONCLUSION

Muscle imbalance is an essential component of dys function syndromes of the musculoskeletal system. Important approaches in the overall therapeutic pro gram lie in the recognition of factors that perpetuate the dys['unction and normalization. This fact is true regardless of whether muscle imbalance is considered to cause the join t dysfun ction or to occur parallel to it.


Can you evaluate the length of each of the muscles which have a tendency to become tight?

•

Can you perform and interpret the six basic movement patterns described in this chapter?

•

Can you identify signs of muscle imbalance from postural or gait analysis?

• REFERENCES I . Janda V. Muscle strength in relation to muscle

length, pain and muscle imbalance. In: Harms Rindahl K, ed. Muscle Strength. New York: Churchill Livingstone, 1 993.

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2. Janda V. Muscle spasm-a proposed procedure for differential diagnosis. J Manual Med 1 99 1 ;6 : 1 36. 3. Janda V. M uscle Function Testing. London: Butterworths, 1 983. 4. Janda V . On the concept of postural muscles and posture. Austl- J Physiother 1 983;29: S83-S84. 5. Janda V . Die M uskularen Hauptsyndrome bei verle bragenen Beschwerden . I n : Neumann H D, Wolff H D, eds. TheOl-etische FOI-tschritte und praktische Erfahrungen der Manuellen Medizin. Konkordia, BiihI 1 978:6 1 -65. 6. Janda V. M uscles, central nervous regulation and back problems. In: Korr I, ed. Neurobiologic mecha nisms in Manipulative Therapy. New York: Plenum Press, 1 978:27-4 1 . 7. Kolar P . Systematization of muscle imbalances fTom the viewpoint of developmental kinesiology. Rehabil i lace Fys Uk 200 1 ;8: 1 52- 1 64. 8. Kolal' P. The sensomotor nature of postural Func l ions. Its fundamental role in rehabilitation. J Orthop Med 1 999;2 1 :40-45. 9. Mense S, Simons DG. Muscle pain: U ndel- standing its nature, diagnosis, and l reatment. Pain associated with increased muscle tension. Baltimore: Lippincott Williams & Wilkins, 200 1 : 99- 1 3 0 . 1 0. Vogt L , Banzer W. Dynamic testing o f t he motorial stereotype in prone hip extension from the neutral position. Gin Biomechan 1 997; 1 2 : 1 22- 1 27 . 1 1 . Vogt L, Pfeifer K, Banzer W. Neuromuscular con trol of walking with chronic low-back pain. Man Ther 2003 ;8:2 1 -2 8. 1 2. Vojta V, Peters A. Das Vojta-Prinzip. Berlin: Springer Verlag, 1 992.

Quantification of Physical Performance Ability

Craig Liebenson and Steven Yeomans

Introduction

Learning Objectives

Rationale-Why


Indications-When

understand:

Physical Performance Ability Test Methods-What

Flexibility/Mobility Strength/Endurance Balance/Motor Control Aerobic Fitness Implementation-How

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•

•

How to evaluate physical performance tests based on their reliability, validity, and practicality. How to administer quantifiable tests of physical impairment that relate to spinal disorders.

Chapter Eleven: Qualification of Physical Performance Ability

Introduction

Functional capacity and physical performance evalu ations have become an i mportant part of the physical examination of work-injured and chronic pain patients (96, 1 00). This unique evaluation is needed because traditional examination methods such as orthopedic, neurologic, and i maging tests are able to accurately diagnose the cause of pain in only approximately 1 0% of patients ( 1 48). When advanced i m aging modali t ies are used, an excessive amount of coincidental findings (high false-positive rate) unrelated to the patients con dition or prognosis are uncovered ( 1 2,24,59,60,6 1 ,66). Amazingly, most tests used in the physical examina tion of musculoskeletal patients are unreliable. For instance, orthopedic tests such as Kemp's or Patrick Fabere's have not been shown to be reliable or to have predktivevalidity ( 1 02,140, 1 4 1 ) . To avoid basing treat ment decisions on often-misleading imaging proce dures, unreliable orthopedic tests, or merely on the patient's subjective self-report of symptoms, the focus of evaluation has gradually been shifting toward iden tification of functional or physical performance deficits (93- 1 0 1 ). One exception is that with the use of diagnostic injections at least 50% of chronic spine pain patients presen ting to specialist diagnostic centers can have the pain generator successfully identified (see chap ter 6) ( 8 , 1 40, 1 4 1 ). However, the cause of the tissue's sensitivi ty m ay not be revealed and therein lies the added value of both physical performance and func tional testing in such patients. Psychosocial factors are also very important in car ing for chronic pain patients and predicting which acute patients are most likely to have chronic pain (see Chapter 9). However, physical performance test ing may reveal salient impairments that were at least partial ly responsible for the pain in the first place (87). This can help to focus the patient on the i mpor tant goal of reactivation and functional restoration. The physical examination can be used for diagnos tic, prescriptive, and outcome purposes. The exami nation of physical performance abi l i ty ( PPA) is a key part of the physical examination because i t can help identify specific impairments responsible for bio mechanical overload of various pain generators (67). Additionally, it can identify impairments related to specific functional limitations that affect an individual in performing their daily tasks at home, work, or sport (4 1 ,9 1 ). This chapter discusses the rationale (why), indications (when), methods (what), and implementa tion (how) related to performing a PPA assessment.

Rationale-Why

The World Health Organization (WHO) h as opera tionally defined f'unction in i ts International Classifi-

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cation of I mpairments, D isabil i ties, and Handicaps ( I C D H ) document ( 5 7) . Most significan tly, the I C D H document distinguishes between general functional ability and specific functional deficits. General func t i onal a b i li ty rela tes to activi ty l evel or di sabi l i ty, whereas specific functional ability i s related to im pairment i n body function. General f,mctional ability or disability is what the patients can or cannot do (or perceive they can do!) in their daily l i fe. This is assessed with activity intolerance questionnaires (i.e., Oswestry, Matheson's activity sorts) (see Chapter 8) or tests of actual patient's general functional abi l i ties such as walking, reaching, carrying, etc. (see Chapter 1 2) . I n contrast , specific functional deficits are found only on clinical examination and may or may not be related to the patient's symptoms or functional abi li ties ( 1 8,34). I n this case i t is the clinician's perception that influences the significance of the find ings. The PPA testing i n this chapter i s m ainly tests of such i mpairments or specific functional deficils. Because t he relationship between specific functional i mpair ments and disability is indirect, the PPA evaluation is but one tool in the evaluation of patients. Evaluation of PPA does not substitute for the lra ditional h istory and examination of orthopaedic, neurologic, or vital signs. Diagnostic triage to iden t i fy patients with "red flags" of serious disease and nerve root compression syndromes is a firs t step in evaluation and requires a focused approach (see Chapter 8) ( 6) when "red flags" are present imaging or laboratory investigations are indicated. If imaging tests are ordered i n the absence of "red flags," they can be m isleading because of t heir h igh false-posi tive rates for clinically insignificant age-related degenera tive findings (9, 1 2, 59, 60,66). Because less than 1 0% of acute patients can receive an accurate, specific d i agnosis, mosl recent guidelines label the remaining 90% as having "non specific" low back pain ( LB P ) ( 6, 1 3 8, 1 42, 1 48). This failure to more accurately d iagnose or classify 90% of L B P has not been deemed a l i m i tation because the condition's favorable natural h istory has been louted. Recent epidemiological studies show that t he course of these "non-specific" low back pain ( L B P ) cases is longer-lasting and more recurrent than previously supposed ( 2 3 ) . The use of the "non-specific" label has been i nterpreted to mean that the majority of patients are a homogenous group who share a uniform cl ini cal picture and prognosis. H owever, what i t more l ikely indicates is that we are not very good at sub classifying a heterogenous group into discreel groups requiring individualized care (70,7 1). Current attempts at providing better care for LBP patients have empha sized i mproving our abil i ty to d iagnose or classify patients into meaningful subgroups (see Chapter 34) (36, 3 8,88, 1 09, 1 50, 1 60- 1 62, 1 69).

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The most i m portan t reasons for perform ing a PPA evaluation are to i dent i fy treatment targets prescri p tive-and establish basel ine levels of func tional i m pairment from which to judge future progress by-outcom es. Establ ish ing a "functional diagnosis" is an i nvaluable clinical guide that can innuence treatment decisions and steer care toward meani ngfu l end points of care . T he PPA evaluation should focus on relevan t functions that can be safely and rel iably measured. Where normative data bases exist, this is most helpful and, whenever possible, us ing tests that include quan t i fication is i deal for outcomes-based reporting. The most val i d tests are those that most closely resemble the actual way we use our bodies in performing activi ties of daily l iving (ADLs). The most valued characteri stic of a fimc tional measure is its u ti l i ty. The u t i l i ty or usefulness of the procedure is the degree to which it meets the needs of the patient, referrer, and payer. Five issues pertaining to a test's u t i l i ty have been described in hierarchical order (Table 1 1 . 1 ) (50,92). H igh-tech instrumentation and dynametric assess ment of the low back have been considered the "gold standard" of lumbar spine functional assessment. This is largely because of their reliabi lity and repro ducibi lity. However, the validity of some of the h igh tech tes ting approaches h as become a source of con troversy (45, 1 20, 1 35). Matheson says, "the inter pretation of the test score s hould be able to predict or reflect the eval uee's performance in a target task" (90). If an e ffort factor can be measured, this will help

Table 1 1 . 1 Key Features of Functional! Performance Tests U t i l i ty (50, 90) 1 . Safety: Given the known characteris tics of the patient, the procedure should not be expected to lead to i njury 2 . Rel iabi l i ty: The test score should be dependable across the evaluators, patients, and the date or time of admin istration 3 . Responsiveness: The test s hould detect clinically meaningful change i n a condition or attri bute over time over and above random improvement 4. Val idity: The interpretation of the test score should be able to predict or reflect the patien t's performance in a target work setting 5. Pract ical i ty: The test should be easy to adminis ter and in terpret. The cost of the test procedure should be reasonable. Cost is measured in terms of the direct expense of the test procedure plus the amount of time required of the patient, plus the delay in providing the information derived [Tom the procedure to the referral source

unmask a malingerer. However, as Dvir has pointed out, t h is is very di fficult to accomplish, especially with strength testing ( 29). Grabiner et a l . has demonstrated that normal strength measurements from a h igh-tech approach do not necessarily correlate with normal human function (45). In t h is study, electromyography (EMG) was used during isometric trunk extension . The results revealed decoupling, or asym metric lumbar paraspinal m uscle activi ty, was present in low back pain subjects who were considered normal on high tech dynametric testing. This decoupling phenom enon was able to differentiate between pain and non-pain subjects. This study suggests t hat muscu loskeletal function i nvolves not only strength but also coordination during the performance of a spec ified task. Because spinal movement and cOOl-dina tion use complex neuromuscular functions, simple strength assessment by high-tech dynamometer does not necessarily correlate with assessment of spinal function. As Lewi t puts i t , " . . . in many fi elds of medicine the i m portance of ch anges in function is now well recognized, whereas i n the motor system, where function is paramou nt, this fundamental aspect is rarely considered. H owever, the functioning of the locomotor system i s extremely complex, . . . and diagnosis of disturbed function is a highly soph isti cated proceeding carried out, as i t were in a cli nical no man's land" (7 8). LaRocca in a Presi den t i al Address to the Cervical Spine Research Soc iety Annual Meeting in Decem ber of 1 99 1 crit ic izes his colleagues for jumping to a psyc hological diagnosis when th ey cannot fi nd a structural cause [or a patient's persistent pai n , ". . . The error here is t h e automatic leap t o psyc hol ogy. I t assumes that all organic factors have been considered, when in reality the clinician's apprecia tion of t he complexity of such factors in often severely l i m i ted" (73). N ewton and Waddell said, "There is no convi ncing evidence t hat isokinetic or any other iso measure has greater cl inical util i ty in the patient wi th low back pain t han either cl inical evaluation of phys ical i mpairment , isometric strengt h, si mple isoiner tial liFting or psychophysical testing" (56, 1 20). At t h e present time, t h e qua l i ty of high-tech tests is not demonstrated sufficien tly to lead to the aban donment o f l ower-tech qual ifiable tests of spinal function. Many rel iable low-tech ways to iden tify functional pathology have been identified. The incli nometer is an example of a very simple tool that can safely provide a great amount of val id and rel iable information. Often a patient's musculoskeletal func tion cannot be quantified. However, qual ifiable tests may be performed that give insight i n to clinically rel evant muscle i mbalances, joint s t i ffness, postural

Chapter Eleven: Quantification of Physical Performance Ability

dysfunctions, and movement incoordination (38, 1 09, 1 1 0,160). Many chiropractors, osteopaths, and manual ther apists use tools that lack reliabili ty such as motion palpation of the accessory movement of joints-com monly called "end feel." Lack of reliability may be caused by a multiplicity of factors (79) and is not a suf ficient reason to abandon a test that is simple, time efficient, and theoretically able to test something i n a way not possible with more accurate or sophisticated means. However, such tests must at least be targeted for research i nto their reliability and val idity or their users risk being considered "cultists" ( 1 25 ) . Rissanen e t al. found that non-dynamometric tests correlated better wi t h pain and disability than did isokinetic tests (88, 1 35 ) . They concluded, "The non dynamometric tests are sti ll useful in clinical prac tice in spite of the development of more accurate muscle strength evaluation methods." Reliability has been reported i n several low-tech tests that do not provide numerical quantification resul ts. For example, the N IO S H Low Back Atlas identified 1 9 tests with sign i ficant reliabi l ity «0.74 Cohen's Kappa and >0.79 coefficient for i nterclass correlation, coefficient [ICC]) ( 1 1 7 , 1 1 8) . M o ffroid et al. studied the ability of the 5 3 N I O S H tests to discri m i nate between low back pain and non painful subjects (90, 1 09). It was found that 2 3 of the 53 tests coul d not d iscrim inate adequately between the two groups and when the seven strongest tests were grouped together, a sensitivity of 87% and specificity of 93% were obtained. I nterestingly, the most i mportant measurements were those t h a t assessed passive mobility, dynamic mobility, strength, and symmetry. H arding et aI., as well as o t hers, reported a group of low-tech tests were determi ned safe, reliable, and val i d for assessment of physical dysfunction in chronic pain subjects (49,9 3 ) . A series of simple trunk and lower extremity endurance tests have been shown be rel iable ( 1 , 1 03 , 1 06 ) . A nor mative database segregated by age, gender, and vocation (blue collar versus w h i te coll ar) were de term i ned for some of these tests on more than 500 individuals ( 1 ) .

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identify key functional pathologies that shou l d be addressed with reactivation care. M ooney reports that the functional capac i ty evaluation shou l d be manda tory for any patient still experienc i ng pain after 6 to 7 weeks ( 1 1 2 ) .

Are Functional Tests Predictive of Short-Term Outcome? •

Fritz et al. reported that a Physical Impairment Index performed on acute patients (6 months postoperative status) exhibit restrictions in center of grayjty displacement during this task, pos sibly because of limited trunk mobility. They com pensate by increasing the displacement of their head to achieve standing (11). It is worth noting that all subjects (with and without LBP) were asymmetrical regarding their performance of the task (12). In the loaded reach task, we have found that pain free subjects reach fl.lrther forward and withstand a greater magnitude of spinal load than patients with LBP regardless of surgical status (37). Not surpris ingly, patients with lumbar fusion compensate for spinal restriction by increasing motion at the hip, knee, and ankle motions compared with the other two groups. They also exhibit relatively lower EMG activity in paraspinal and rectus femoris muscles but greater EMG activity in gluteus and hamstrings mus-

cles compared with control subjects or with non surgical patients. The interdependency in the relationship between movement and EMG activity makes it difficult to determine whether differences in EMG activity be tween groups are causes, correlates, or consequences of altered movement patterns. More importantly, the adaptive strategies distant from the trunk (e.g., be tween group differences in ankle movements) empha size the need for "whole person" assessment rather than spinal assessment. Interestingly, non-surgical patients with LBP ex hibit significantly greater lateral sway as they move forward (22.36 em, compared to 10.88 em and 11.11 em for spinal fusion and control groups). It is possible that this increased lateral sway is pain related because of the relatively high level of pain in

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A At preferred walking speed

60 o

50

Norm

.BP o LP

40 30 20 10 o Ankle

Knee

Hip

Lumbar

Lumbar

Flex/Ext

Side Flex

B At fastest walking speed

60 o Norm • BP

50 40 30 20 10 o Ankle

Knee

Hip

Lumbar

Lumbar

Flex/Ext

Side Flex

Figure 12. 1 1 Total range of motion during a gait cycle. (A) At preferred walking speed. (B) At fastest walking speed.

the non-surgical patients. It could also be caused by the relatively slow rate of forward movement in the LBP group resulted in greater lateral sway (similar to riding a bicycle slowly). The fact that this study was cross-sectional in design limits the interpretation of these findings.

• CONCLUSION

Physical performance and LBP are complex multi dimensional constructs. They can be influenced by physical, cognitive, emotional, social, task, and environmental factors. The physical performance task battery appears to provide a psychometrically sound and meaningful basis for physical therapy

assessment, treatment, and outcome measurement. It is plausible that physical performance tests will also provide a reasonable basis by which patients are divided into homogenous subgroups. Thus, individual treatment protocols for the subgroups can be developed based on a theoretically credi ble and testable foundation. Monitoring physical performance over time may ultimately facilitate clinical decisions regarding optimum timing and duration of physical therapy interventions. Another advantage 0f using physical performance tests for assessment is that clinical decisions can be driven into a mode that is more holistic, that focuses on physical function and activity, that identifies move ment difficulties, and that has a credible, theoreti cal basis.

Chapter Twelve: Physical Performance Tests

A

B

c

D

Figure 12.12 B iomechan ical analysis of sit-to-stand task.

(A) (B) (C) (D)

Condition I: Arms pus h i n g fl-om chair. Cond ition 2: Arms crossed. Cond i t i o n 3: Arms fl-ee. Cond i t ion 4: Arms push i ng knees.

A

B

Figure 12.13 B i o mechanical analysis of loaded reach task.

(A) Starting posit �on. (B) End pos i t i o n .

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Why are i m pairment tests not related significantly to the actual phys i ca l performance o f tasks?

•

What tests are part of the standardized battery of fu nctional tests?

•

H ow can t h i s functional battery i n fluence the type of care delivered?

•

How are functional tests affected by back pain and sciatica?

•

How i s gait affected by back pain and sc iatica?

• REFERENCES 1 . Aren dt-Niel sen L , Graven-Nielsen T, Svarrer H , et al . The i n Auence of low back pai n on muscle activi ty and coord i nation during gait: a c l inical and experi mental study. Pain 1 996;64: 2 3 1 -240. 2.

Beurskens AJ , de Vet HC, Koke AJ. Responsiveness o f fu nct ional status in low back pai n : A comparison o f d i fferent instru ments. Pain 1 996;65 : 7 1 -76.

3.

Beurskens AJ, de Vet H C , Koke AJ, et a l . Measuring the flmctional status of patients w i t h low back pain. Assessment o f the qual i ty o f four d i sease-specific questionnaires. Spine 1 99 5 ; 20: 1 0 1 7- 1 02 8 .

4.

Biering-Sorensen F , Thomsen CE, H ilden J . R i s k i n d i cators for low b a c k trouble. Scand J Rehabil M e d 1 989;2 1 : 1 5 1 - 1 5 7 .

5 . Chatman A B , Hyams S P , Neel J M , et a l . The Patient Spec ific Functional Scale: measurement propert ies in patients w i t h knee dysfunction. Phys Thel" 1 99 7 ; 7 7 : 8 2 0-82 9 . 6 . Craig KD, Prkach i n K M , G m n a u R V E . T h e facial expressi on of pain . I n : Turk DC, Melzack R , eds. The facial expression of pain. Gu i l ford Press, 1 992:257-2 7 6 . 7 . de Looze M P , Z inzen E , Caboor D , et al . M uscle stren gth, task performance and low back load in nurses. Ergonomics 1 998;4 1 : 1 095-1 1 04. 8.

Dedering A, Nemeth G , Harms-Ringdahl K. Correla tion between electromyograph i c spectral changes and subjective assessment of l u m bar muscle fatigue in subjects wi t h out pain from the lower back. Clin Biomech ( B ri stol , Avon) 1 999; 1 4: 1 03- 1 1 1 .

9.

Deyo RA, Centor RM . Assessing t he responsiveness o f fu nctional scales to c l i n ical c hange: An analogy to d i agnos t i c test perform ance. J Chro n ic D i s 1 986 ;39:8 97-906.

1 2 . E tnyre B R , Sim monds M J , Radwan H. Comparison o f electromyographic duration and frequency c har acteristics between low back pain patients and a con trol group. Third I n terdiscipli nary World Congress on Low Back and Pelvis Pain. Vienna, Austria, 1 998. 1 3 . E tnyre B R , Sim monds M J , Radwan H , et a l . H i p and knee d isplacements during s i t -to-stand movem ents between low back pain patients and a control group. 1 3t h I n temational Congress of World Confederation for Physical Therapy. Yokohama, Japan, J 999. 1 4. Faas A . Exerc ises: Which ones are worth t ry i ng, for which patients, and when? Spine 1 996 ; 2 1 :2 874-287; d i scussion 2 8 8-2 89. 1 5 . Fairbank JC, Couper J , Davies J B , et al. The Oswestry low back pai n disa b i l i ty quest ionnaire. Physiother apy. 1 980;66: 2 7 1 -2 7 3 . 1 6 . F i s her K, Johnston M . Validation of t h e Oswestry Low Back P a i n Disab i l i ty Questionnaire, its sensitiv ity as a measure o f change following treatment and its relationship w i t h o t her aspects o f the chronic pain experience. Physiother Theory Pract 1 997; 1 3:67-80. 1 7 . Fordyce WE, Lansky D , Calsyn DA, et al. Pain mea surement and pain behavior. Pain 1 9 84; 1 8 :53-69. 1 8 . Freburger JK, Riddle DL. U s i ng publ ished evidence to guide the exam i nation of the sacroil iac joint region. Phys Ther 200 1 ;8 1 : 1 1 3 5- 1 1 43 . 1 9 . Gatchel R J , Pol a t i n P B , Mayer T G . T h e dom i nant role of psychosoc ial risk factors in the development of chron ic low back pain disab il ity. Spine 1 99 5 ; 20:2702-2709. 20. Grieve GP. Mobil izat ion o f the Spine, 4th ed. New York, N Y: Churc h i l l Livi ngstone, 1 984. 2 1 . Hussein TM. Kinematic gait characteristics: A com parison o f patients with chronic low back pai n with and w i t hout refelTed leg pa i n ( D issel-tation). Hous ton, TX: Texas Woman's U n i versity, 1 999. 22.

Hussein T M , Si m m onds MJ , Et nyre B , et al. Kine matics o f gait i n subjects w i t h low back pa i n with and w i t hout leg pain. Washington, DC: Sc ien t i fic Meeting & Expo s i t i on of the American Physical Therapy Association, 1 999.

23. H ussei n T M , S i m monds MJ , Olson SL, et a l . Kine matics of gait in normal and low back pain subjects. Boston, MA: American Congress of Sports M edicine 45th Annual Meeti ng, 1 99 8 . 2 4 . I to T, S h i rado 0 , Suzu k i H , et a l . Lumbar trunk mus cle endurance testi ng: An i nexpensive altemative to a mach ine for evaluat i o n . Arch Phys Med Rehabil 1 996;77:75-79. 25. Kankaanpaa M, Laaksonen D , Taimela S, et al. Age, sex, and body mass i ndex as determ inants of back and h i p extensor fat igue in t h e isometric Sorensen back endurance test. Arch Phys Med Rehabil 1 998; 79: 1 069- 1 0 7 5 .

1 0 . Donahue MS, Riddle DL, Sull ivan MS. I ntertester rel iability of t he modified version o f M c Kenzie's lat eral s h i ft assess ments obtai ned i n pat i e n ts with low back pai n . Phys Ther 1 99 6 ; 7 6 : 706-7 1 6 .

26. Lee CE, S i mmonds MJ , Novy D M , et a l . Self-reports and clin ici an-measured physical perform ance among patients with low back pain: A comparison. Arch Phys Med Reha b i l 200 1 ;8 2 : 1 n press.

1 J . Etnyre BR, S i m monds M J , Lee C E , et al . Head and center of gravi ty motion during s i t - to-stand between back pain pa tients and a con trol grou p . 1 3 t h I nterna t i onal Congress of World Confederati o n for Physical Th erapy. Yokohama, Japan, 1 999.

2 7 . M a i n CJ , Watson PJ . Screening for pat ients at ri sk of developing chron ic i ncapac ity . J Occup Rehabil 1 99 5 ; 5 :207-2 1 7 . 2 8 . M arras WS, Parnia npour M, Fel"guson SA, et al. The classification of anatomic- and symptom-based low

Chapter Twelve: Physical Performance Tests

back disorders using motion measure models. Spine 1 995 ;20:2 5 3 1 -2 5 46 . 2 9 . MalTas WS, Wongsam P E . Flex i b i l ity and velocity o f t h e normal a n d i m paired l u m bar spine. Arch Phys Med Rehabil 1 9 86;67:2 1 3-2 1 7 . 30. McHorney CA, Ware JE Jr, Lu JF, et al. T.he MOS 36-i tem Short-Form H ea l t h Survey (SF- 3 6 ) : I I I . Tests of data qua l i ty, sca l i ng assumptions, and rel i a b i l i t y across diverse patient grou ps. M e d Care 1 994;32:40-66. 3 1 . McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): I I . Psy chometric and c l i n ical tests of validity in measuring physical and mental health constructs. Med Care 1 993;3 1 :247-2 6 3 . 3 2 . Newton M , Thow M , Somerville D , et a l . Trunk strength testing w i t h iso-mach i nes. Part 2 : Experi mental eval uation of the Cybex II Back Tes t i ng Sys tem i n normal subjects and pat ients with chronic low back pai n . Spine 1 99 3 ; 1 8 : 8 1 2-824. 33. Novy D M Sim monds MJ, Lee CE Physical Perfor mance Tasks: What are t he Underlying Constructs? Arch Phys Med RehabiI 2002 ;8 3 ( I ) :44-47. 34. N ovy D M , Simm onds M J , Olson SL, et a l . Physical performance: di fferences i n men and women with and wi thout low back pai n . Arch Phys Med Rehabi l 1 999;80: 1 95-1 98. 3 5 . Perry J. Gait Analysi s : Normal and Pathological Functi o n . Thorofare, NJ: SLACK Inc, 1 99 2 . 36. Radebold A, Cholewicki J , Polzhofer GK, et a l . Impaired postural control of the l u mbar spine i s associated with delayed muscle response t i mes i n patients w i t h chronic idiopathic l o w back pain. Spine 200 1 ; 26:724-7 30. 3 7 . Radwan H A . Motion patterns, electromyographic activity, and ground reaction forces during a loaded functional reach task: A comparison among subjects with low back pai n , subjects w i t h l u mbar spine fusion and a control group ( D issertat i o n ) . Houston, TX: Texas Woman's U n i versity, 1 999. 3 8 . Roland M , M orris R . A study o f the natural h i story of back pa i n . Part I : Development of a rel iable and sen sit ive measure of disabi l i ty in low-back pa i n . Spine 1 98 3 ; 8 : 1 4 1 - 1 44. 39. Rudy TE, Boston JR, Lieber SJ, et al. Body motion patterns duri ng a novel repetit ive wheel-rotation task. A comparative study of healthy subjects and patients with low back pai n . Spine 1 995 ;20:2 547-2 554.

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40. Sanders SH. Automated versus self-moni toring of 'up-ti me' i n chronic low-back pain patien ts: A com parative study. Pain 1 98 3 ; 1 5 : 3 99-405 . 4 1 . Sharrack B , H ughes RAC. Rel i a b i l i t y o f di stance esti mation by doctors and patients: Cross sec t ional study. BMJ 1 99 7 ; 3 1 5 : 1 652- 1 654. 42 . Simm onds MJ, Campbell A , Wang WT. Assessing functional change i n pat ients w i t h low back pain: A comparison of measures. Yokohama, Japan: 1 3 t h I n ternati o nal Congress o f the World Confedera tion for Physical T herapy, 1 999. 43 . Simmonds MJ, Claveau Y . Measures of pain and physical function in patients with low back pai n . Physiother Theory Pract 1 99 7 ; 1 3: 53-6 5 . 44. S i m monds M J , Lee CEo The Sorensen endurance test: a test of fatigue or pai n ? Phoenix, AZ: American Pain Society, 200 1 . 45. S i m m onds M J , Lee C E , Jones Sc. Pai n distri bution and physical fu nction i n patients w i t h l ow back pain . Yokoh a m a , Japa n : 1 3 t h I nternati onal Con gress o f the World Con federation for Physical Therapy, 1 999. 46 . Simmo nds M J , Olson S , N ovy D M , et al. D i sa b i l i ty pred i c t i o n i n patients w i t h back pain using perfor mance based models. C h arleston , SC: Nort h Amel-ican Spine Society/American Pain Society Meeting, 1 99 8 . 4 7 . S i mmonds M J , O l s o n S L , Jones S, et a l . Psyc homet ric c haracteristics and c l i nical usef'u l ness o f physical performance tests i n patients w i t h low back pai n. Spine 1 998;23:2 4 1 2-242 1 . 48 . Stratford P , G i l l C , Westaway M , et aJ. Assess ing d is ability and change on i nd ividual patients: A report o f a patient specific measure. P hysiot her Can 1 99 5 ;47:2 58-263. 49. Turk DC, Rudy TE, Stieg RL. The d i sabi l i ty determ i n a t i o n d i lemma: Toward a m u l t i axial sol ution. Pain 1 988;34:2 1 7-229. 50. Vlaeyen JW, Kole-Snijders A M , Boeren RG, et a J . Fear of movementl(re ) i nj u ry i n c h ronic l o w back pain and i ts relation to behavioral performance. Pain 1 99 5 ; 62 : 3 6 3-372 . 5 1 . Waddell G , Newton M , Henderson I , e t a J . A Fear Avoidance B e l iefs Quest ionnaire ( FA B Q ) and t h e role of fear-avoidance beliefs in chron i c low back pa i n a n d d i sabi l i ty. P a i n 1 99 3 ; 5 2 : 1 5 7- 1 68 . 5 2 . Ware J E Jr, Sherbourne C D . T h e M O S 36-i tem short form health survey ( S F- 3 6 ) . I . Conceptual framework and i tem selecti o n . Med Care 1 99 2 ; 3 0 : 473-48 3 .

Employment Screening and Functional Capacity Evaluation to Determine Safe Return to Work

-

Leonard Matheson and Vert Mooney

Introduction

Learning Objectives

Validity of Pre-Employment Pre-Placement Screening Pre-Placement and Fitness for Duty Screening

On completion of this chapter you should be able 10: •

Americans With Disabilities Act

•

Fitness for Duty Evaluation

•

Pre-Placement Screening Screening by Health Care Professionals

•

Role of the Treating PhYSician Role of the Evaluating Physician

•

Functional Capacity Evaluation

•

•• 276

Assess the validity or pre-employment and pre-placement screening. Define fitness for duty evaluation. Explain the American and Disabilities Act restrictions and protections. Define the roles of the treating physician versus the evaluating physi cian. Assess the validity of a Functional Capacity Evaluation and be aware of what it can tell about job capacity. Assess the appropriate physical therapy and the expectations of physical therapy reporting.

•

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

Introduction

This chapter describes the historical background of employment screening from a health care perspec tive, beginning with the use of spinal x-rays to screen for risk of injury. Medical examination is less useful and justified for employee selection than it is for baseline comparisons. The use of technologies such as spinal MRI procedures may provide a basis for avoiding expensive and needless surgery when a problem such as an asymptomatic degenerative spine is found to be present before employment. The use of functional capacity evaluation is more often justi fied, both to identify applicants for employment who will be the most productive workers and to assist the physician and plant manager to properly place a worker returning from sick leave. Validity of Pre-Employment Pre-Placement Screening

It is self-evident that an employer would like to avoid hiring those who have greater liability of injury than the average. Recent estimates of direct costs of work related injuries and illnesses in the United States are in excess of $65 billion. In addition, the indemnity costs are $106 billion to American Industry (48). What can be done at the onset of employment to reduce the incidents of the employed? This chapter addresses employment screening for new employees and those who are returning to work after experi encing lost time because of injury or illness. The earliest form of pre-employment testing was the use of back x-rays. In early years it was felt that abnormal findings could predict those who would have injuries at work. However, when scientific stud ies were initiated, it was found that in asymptomatic people, 10% had disc degeneration, spondylolysis, or spondylolisthesis (25). Actually, when studied, it turned out that people with "normal" radiographs actually had a higher rate of injury compared to those who showed radiographic abnormalities (43). In another study in a steel plant where the workers were performing heavy work, abnormalities seen in x-ray did not predict a higher incidence of low back injuries (1 3). This is to be expected of course. The incidence of spondylolysis is approximately 5% in the U.S. general population, but the rate of significant disabling back pain in Americans with spondylolysis is only approxi mately 0.5% (2). Thus, because of the lack of predictive validity, and with the additional awareness of the threats of radiation, pre-employment radiographs have not been demonstrated to be cost-effective. Of course the more modern imaging technique is the MRI. This is extremely sensitive to soft tissue changes in the disc, but no study has showed that

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abnormalities noted in MRI are predictive of later pain symptoms. There is, however, a possible ratio nale that can be applied to a lumbar MRI if it could be performed cheaply enough. It is well-recognized that degenerative changes in the spine increase in a rate approximately correlated with age. Currently, when a worker is injured, the MRI shows a significant degen erative change and the individual does not respond to undefined physical therapy, a justification is made for fusion, whether there is causal evidence for impair ment. If it can be demonstrated that the degenerative changes that are suggesting the need for fusion were actually found in the MRI when the worker was hired (and the worker had been successfully employed in the interim), the enthusiasm for surgery is decreased. This strategy apparently has been successful in reduc ing the incidence of the very expensive spinal fusions at the Steelcase company (39). It is not clear whether in the future that the safer, but the more expensive, imaging tool MRI compared to plain x-rays will be more helpful than the now discarded x-ray screening. If imaging studies are not predictive of spinal dis ease, then how about physical strength testing? There only has been one study that purports to demonstrate that strength testing could predict an incidence of back injuries (24). The workers studied in this group performed extremely demanding physical work in the tire manufacturing business. They had to lift heavy tires off of workplaces, twist, and put them down in a constant repetitive manner. The heavy job demands facing that group of workers is somewhat unique. Using essentially the same testing method, a more recent study of pre-employment testing of air craft workers for Boeing indicated that isometric testing of total body lift function could not predict of incidence of back injury (3). Selection for employment on the basis of lifting tests is not possible unless the specific demands of the job are being tested. In another recent study, careful strength testing using isokinetic technology was performed on 33 experienced warehouse work ers to measure back strength. The pre-placement individuals had to meet that minimum standard before they were hired in that job category. There was a significant reduction in back pain claims as a result of this strategy (44), but such a study may bring up another aspect of pre-placement testing. An applicant for the job, when it is recognized that spe cific testing is being performed, may not persist with the application for that job if he/she feels physically poorly qualified or has a history of workers' com pensation claims. Pre-placement strength testing can give a baseline that would question the validity of an individual's claim for injury later. Is there evidence that back strength is a predictor for back injury? We conducted a study to investigate

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that proposition (35). Using specific isometric testing over 7 points of range, we tested 1 52 shipyard work ers as to their lumbar extensor strength. These indi viduals were all veterans in their job, had not had back claims for at least 3 years, and were followed-up for an additional 2 years. Nine percent of that study group had a back claim over the next 2 years. It was noteworthy that all but two of these injured workers had higher strengths than the average. Thus, back strength itself was not a predictor of injury. These workers were classified also regarding PDC levels of medium, heavy, and very heavy work. Even though they performed various types of work with varying physical demands, the back strengths did not vary among these three groups. Thus, even the demands of the job did not apparently affect back strength. Are there factors that can predict work injury? Chaffin and Clark found a threefold increase of injuries and the risk of back problems in subjects with a history of back pain (8). Sciatica is a predictor of back pain (38,4). A prospective study by Lloyd and Troop (27) found four historical factors to be predic tive of recurrent low back pain. These were residual leg pain on work placement, history of sickness absence of 5 weeks or more, falls as a cause of back pain, and a history of two or more previous episodes of back pain. Thus, we do have some predictors of who might get industrial back pain. With this knowledge, is it possi ble to disCliminate in hiring practices? In 1984 the American Medical Association summarized the objec tives for pre-placement examinations as follows ( 1 5): •

•

•

•

To evaluate the medical fitness of individuals to perform their duties without hazard to themselves or fellow workers. To assist employees in maintaining maintenance or improvement of their health. To detect the effects of harmf·ul working conditions and to advise corrective measures. To establish a record of the medical condition of the employee at the time of each examination.

However, there was a considerable question as to whether the employees or the employer benefited from medical evaluation programs at all (16). Actu ally, there never has been a scientific study demon strating the levels of success or risk of avoidance accomplished by medical evaluations in the past. In fact, the case was being made that even evaluation was discriminating in preventing people with dis abilities from entering the workplace. Thus, the American with Disabilities Act (ADA) passed in 1 990. It prohibits disability-based discrimination in all

aspects of employment and mandates that medical examinations be conducted only after an offer of employment is made to an applicant. An employer cannot reject a candidate because of medical con cerns about insignificant or uncertain future risks or inability to perform non-essential job functions. Employers are required to maintain the confiden tiality of medical information and to provide reason able accommodations for qualified applicants who have disabilities. In the past it was possible for physicians to rec ommend to employers that they do not hire appli cants because of speculative risks of injury or costs of accommodation. Under the ADA, the incorrect medical advice can result in significant and costly lit igation. Thus, any medical advice has to be specifi cally based on appropriate evidence. Employers may require an applicant to undergo the physical examination before beginning employ ment, but only after a job has been offered. The rea son for conducting such an evaluation may include medical determination of the ability to meet job per formance requirements or medical standards. The ADA allows an employer to reject a person only after stringent criteria are met. An applicant may be rejected if he poses a direct threat to himself or oth ers in the workplace. He may be rejected if a disabil ity prevents performance of essential job functions or when accommodations cannot be made without undue hardship. This phase of the legislation may result in litigation as to what is accommodation that would create undue hardship to the employer. Specifically, also, the ADA prohibits employers to inquire about a history of back problems, which the job applicant may choose not to disclose, before a job offer. The Equal Employment Opportunity Commis sion (EEOC) notes that 46% of back impairment charges have come from discharged employees ver sus 1 5% in the hiring process (22). Let's take a closer look at the laws and guidelines surrounding health care practice in employment screening.

Pre-Placement and Fitness for Duty Screening

Increasingly, health care professionals are being asked to provide pre-placement screening and fitness for duty screening services. It is important to recog nize that these services must be provided within the context of the laws that govern employee placement and selection. This legal context is quite different from that in which all other laws based on the Eng lish Common Law heritage are found. That is, the laws governing employee placement and selection are frequently concerned with establishing parity for


disadvantaged individuals. The Equal Employment Opportunity (EEO) laws in the United States, and similar laws in Canada and most industrialized countries, are intended to precipitate social change. As such, the laws and the rules governing those laws have developed so that they favor the employee or potential employee who chooses to use them. In all other aspects of the law, the individual against whom an action is brought (the defendant) does not have the burden o[ proof. The plaintiff or applicant who brings the action maintains the burden of proof and, if the plaintiff is not able to establish beyond a rea sonable doubt that the defendant is at fault, the defendant will win the lawsuit. The difference in the EEO arena is that the burden of proof is on the defen dant. In an EEO action, the defendant must demon strate that there was no unfair discrimination in the defendant's hiring, placement, or promotional procedures. The EEO laws have been developed in recognition of the fact that discrimination exists within society based on factors other than ability. The basic tenet of these laws is that one must not unfairly discriminate. Discrimination in selection for employment and [or placement after hiring is only acceptable as long as it is fair and appropriate to the situation. If a selec tion procedure is used and decisions for placement are made based on the results of the selection proce dure, it must be able to be demonstrated that the selection procedure is relevant to the decision that was made. For example, it is entirely appropri ate to use a test of typing speed and accuracy to select indi viduals to be placed in a job in which typing is a nec essary and important job [unction. However, this same test would not be appropriate for individuals applying for a job as a warehouse worker if typing is not a necessary part of that job. To use another example, a test of infrequent lifting from floor to eye level would be appropriate as long as the evaluation task can be demonstrated to predict subsequent com petence and/or safety in the warehouse worker's job. It would only be appropriate to use that same test of lifting with a secretary if the secretarial job descrip tion required lifting as a usual and necessary job [·unction. In either case, the test must be such that the individual's performance can be shown to be related to subsequent performance on the job. It is important to appreciate that the applicant's competence in performance of job functions must be considered separately from the applicant's safety i n the job. Although in most health care professionals' minds these are linked, competence and safety are separate issues and must be considered separately. The important point here is that assessment of com petency is much easier to perform and defend than assessment or safety. The health care professional

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who is providing pre-placement evaluation services probably will be best able to provide tests of compe tency rather than tests of safety when one considers the legal context within which all of the testing must be conducted. Stated another way, the evaluator must be prepared to defend his or her recommenda tions against a challenge based on one or another (or perhaps several) of the EEO laws. It is much easier a priori to develop an effective defense if the recom mendation for placement is based on competence than i f the recommendation is based on safety. In addition, if, for some reason, an a priori defense has not been developed and the evaluator is unprepared, a defense based on competence will be possible to reconstruct, whereas a defense based on safety will be impossible to put together after the fact. The defense that an employer will use has to do with: 1. Whether the individual is a member of a pro tected group. 2.

Whether the use of the selection device brought about an adverse i mpact.

3. Whether the use of the selection device can be demonstrated to be based on a business necessity.

If an i ndividual is not from a protected group, and/or there i s no adverse i mpact, and there is a business necessity for use of the test, then the employer will prevail. However, if an individual is a member or a protected group and there is adverse impact without business necessity, the plaintiff will prevail. Even if the employer puts forth an adequate defense, individuals in the United States who are members of the disabled protected group have still another set of protections based on the legal require ment that the employer provide reasonable accom modation. That is, the employer must demonstrate that i t is not reasonable to make changes in the work place or manner of work that would sufficiently accommodate the handicap presented by the prospec tive employee so that job performance would not be affected. Because each of the States in the United States can develop laws that extend beyond the basic re quirements of the federal EEO laws, various defini tions have come up that are relevant in certain states. For example, the definition of "handicapped worker" includes individuals who are hypertensive in Cal i fornia but does not apply in any other states, includes individuals who are alcoholics in Wisconsin but does not apply in any other states, and includes i ndividuals with glaucoma in North Carolina but does not apply in any other states. Conversely, cer tain states have delimited the term. The important point to appreciate is that there is great variability.

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The laws briefly outlined should be considered basic. The protections that are described for workers may have been expanded by a particular state or munici pal government. Title VII of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, national origin, sex, or religion. This Act is enforced by the Equal Employment Opportunity Commission. Title VII includes employers that have 15 or more employees that are engaged in "an industry affecting commerce," all state and local governments and schools, almost all unions, and almost all employ ment agencies. Executive Order 11246 (1965) amended by Execu tive Order 11375 (1968) prohibits discrimination on the basis of race, color, religion, or national origin by contractors doing business with the federal govern ment. This is administered by the Secretary of Labor through the Office of Federal Contract Compliance Programs. Any employer who has a contract of $10,000 or more or who does business with the fed eral government worth $50,000 or more is covered. The Age Discrimination and Employment Act of 1967 (ADEA) was amended in 1978 and protects employees and applicants for employment between the ages of 40 and 70 years. Employers with 20 or more employees for 20 or more weeks of the year are included. Enforcement of the ADEA is vested with the Equal Employment Opportunity Commission. The Equal Pay Act of 1963 is an amendment to the Fair Labor Standards Act of 1938 and is the basis behind the "Equal Pay for Equal Work" movement, which requires that employers provide wages to employees at a rate that is not gender-specific. This is currently under the jurisdiction of the Equal Employment Opportunity Commission. The Health Care Act of 1973 is similar to Execu tive Order 11246 and Executive Order 11375 but extends the protection to individuals who are handi capped and expands the threshold for coverage to any contractor who has more than $2,500 of busi ness with the federal government. A handicapped person is covered if he or she has a physical or men tal impairment that substantially limits one or more major life activities or has a record of such impair ment or is regarded by others as having such an impairment, even though the person may not, in fact, have such an impairment. Under Section 504 of the Act, an employer may not inquire about whether the applicant is handicapped or about the nature or severity of a handicap unless two criteria are met: 1.

A pre-employment medical examination is required of all applicants.

2.

The information sought is relevant to the appli cant's ability to perform job-related functions.

Although, originally, individuals with alcohol or drug abuse problems were considered handicapped, subsequent amendments by Congress have excluded this as a handicapping condition. The Health Care Act is administered by the Office of Federal Contract Compliance Programs. The OFCCP has administra tively expanded the concept of handicap to include, for instance, obesity and epilepsy. In addition, the concept of reasonable accommodation has been developed by the OFCCP. The Health Care Act itself does not require the employer to make reasonable accommodation. The Vietnam Veterans Readjustment Act of 1974 covers disabled veterans and non-disabled veterans of the Vietnam era and is similar to the Health Care Act of 1973 and the Executive Orders 11246 and 11375 in that it covers contractors with the federal government wherein the value of the contract is $10,000 or greater. This is also under the jurisdiction of the Department of Labor, administered through the Office of Federal Contract Compliance Programs.

Americans With Disabilities Act

The Americans with Disabilities Act was signed into law by President George Bush on July 26, 1990. The Act states that: No covered entity shall discrimi nate aga inst a quali fied individual w i t h a disabi l ity because of the disab i l ity of such ind ividual in regard to job application procedures, the h iri ng, advancement, or disch arge or employees, employee compensation, job traini ng, and other terms, conditions, and privi leges or employment.

Purpose of the ADA

In the ADA, Congress attempted to address several important issues that had been introduced and less effectively addressed in the Health Care Act of 1973. These include: 1. To provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities. 2.

Provide clear, strong, consistent, and enforceable standards that address discrimination against individuals with disabilities.

3. To insure that the federal government plays a central role in enforcing the standards in the Americans with Disabilities Act on behalf of indi viduals with disabilities. 4.

Invoke Congressional authority, including the power to enforce the 14th Amendment and to regulate commerce to address the major areas


of discrimination faced by individuals with disabilities.

Types ofDiscrimination Targeted by the ADA Congress recognized that discrimination against indi viduals with disabilities takes several forms and exists in a number of areas. Discrimination limits individu als with disabilities in areas of employment, housing, access to public facilities, and access to public trans portation and communication. With regard to dis crimination against individuals with disabilities in the area of employment, Congress specifically identified the following as covered by the Act: 1 . Limiting, segregating, or classifying the disabled. 2.

Participating in a contractual relationship that has the effect of subjecting employees to discrim ination prohibited by the Act.

3. Utilizing standards that have the effect of dis crimination based on disability. 4.

Basing employment decisions for a qualified individual on the known disability of the person with whom the qualified individual is known to have a relationship.

5. Not making reasonable accommodations to the limitations of the qualified individual unless the covered entity can demonstrate that this would pose undue hardship on the operation of the business. 6. Using qualification standards that screen out or tend to screen out individuals with disabilities, unless the standard is shown to be job-related and is consistent with business necessity. 7.

Using employment tests that reflect the individ ual's impairment rather than providing a valid measure of the job's demands.

Definitions Provided by the ADA As is necessary with every law, certain definitions are developed and provided by Congress to be used by agencies enforcing the law. Those that relate specifi cally to the employment aspects of the Act include: Disability-A physical or mental impairment that substantially limits one or more major life activities; a record of such impairment; or being regarded as having such impairment. Covered entity-An employer, employment agency, labor organization, or joint labor action committee. Employer-A person engaged in an industry affecting commerce who has 15 or more employees in each of 20 or more calendar weeks in the current or preceding year. For 2 years after

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the effective date, "employer" is a person engaged in an industry affecting commerce who has 25 or more employees in each of 20 or more calendar weeks in the current or preceding year. The effective date for the legislation is July 26, 1990. Therefore, employers with 25 or more employees are covered as of July 26, 1992, and employers with 15 or more employees are cov ered as of July 26, 1994.

Qualified Individual with a Disability An individual with a disability who, with or without reasonable accommodation, can perform the essen tial functions of the job that he/she holds or desires. The Act provides a non-exhaustive set of conditions or disorders that are specifically excluded fTom the definition, including homosexuality, bisexuality, transvestitism, pedophilia, transsexualism, exhibi tionism, voyeurism, gender identity disorders not resulting from physical impairment, other sexual behavior disorders, compulsive gambling, kleptoma nia, pyromania, and psychoactive substance abuse disorders resulting from current illegal use of drugs. In addition, an amendment to the Health Care Act of 1973 states that "individual with handicaps" does not include an alcoholic whose current use of alcohol prevents performance of job duties or constitutes a direct threat to property or to the safety of others. Direct threat-As part of a qualification stan dard, an employer may exclude a qualified indi vidual from employment if that individual can be shown to pose a direct threat to the health and safety of others in the work place. This must be a significant and identifiable risk, not merely an elevated risk. The employer must demon strate that the individual poses a direct threat. The plaintiff is not required to prove an absence of risk. Essential functions of the job-Consideration shall be given to the employer's judgment as to what functions of the job are essential. A written job description, prepared before advertising or interviewing, shall be considered evidence o[ the essential [unction. However, there is no pre sumption in favor of the employer's judgment. The weight that evidence based on job descrip tion will be given will depend directly on how closely it is tailored to the essential duties of the actual job. Reasonable accommodation-This is not specifi cally defined. As was the practice with the Health Care Act of 1973, reasonable accommodation takes many forms and is dependent on the employee, job, covered entity's facility, and

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covered entity. Reasonable accommodation is based on procedures that have been developed to implement the Health Care Act of 1973. The Amer icans with Disabilities Act introduces reasonable accommodation with the phrase, "the term 'rea sonable accommodation' may include. . . ." The act provides specific examples, including making existing facililies readily accessible to and usable by individuals with disabilities. In addition, other methods of restructuring include job restructuring, part-time or modified work sched ules, reassignment to a vacant position, acquisi tion or modification of equipment, modification of examinations, training materials, or policies, provision of readers or interpreters, or other similar accommodations. Undue hardship-An action requiring significant difficulty or expense. This is considered in light of the accommodations and how they are to be implemented, involving both the direct cost and net cost of the accommodations. In addition, the facility's financial resources, number of persons employed, and impact on operations is taken into account. Beyond the individual facility, the covered entity's resources are considered based on the financial resources of the entity, the num ber of persons employed, and the impact on operations of the entity. Finally, the composi tion, structure, and function of the work force at the entity and the facility's geographic separate ness fTom administrative control, along with the physical relationship of the facility to the covered entity will be taken into account. Determination of undue hardship is factual and is made on a case-by-case basis. The burden of proof is on the employer.

Fitness for Duty Evaluation

As the disabled individual concludes his treatment program and is released by his physician, determi nation regarding return to work at the usual and cus tomary employment, requirement of reasonable accommodation, or a decision of no return to employment despite accommodation, is based on a fitness for duty evaluation (FFDE). The FFDE is a content-valid functional capacity evaluation based on the previously conducted physical demands job analysis. The FFDE is conducted by a health care professional with proper education, training, and experience. The FFDE is based on the critical job tasks of the target job. These are identified by review ing the physical demands job analysis in light of the employee's impairment. The FFDE process follows these steps:

1 . Physical demands job analysis review-The fit ness for duty evaluation begins with review and confirmation of the physical demands job analy sis in consultation with the supervisor, employee, and treating physician to identify the critical job tasks that will be the focus of the evaluation. 2.

Medical records review-A review of pertinent medical records is undertaken, facilitated by contact with the evaluee's physician if the eval uee is in active treatment. Confirmation that the impairment is stable and identification of work restrictions that may affect subsequent testing are the focus of these activities.

3. Structured interview-A structured interview between the evaluator and evaluee is confidential and focuses on the evaluee's injury and medical history. In addition, the evaluee's perception of current functional limits is reviewed. The pur pose of the interview is to begin screening out individuals who cannot be tested safely and to identify performance limits that may not be apparent. 4.

General health questionnaire-The evaluee must complete a general health questionnaire and injury history. A questionnaire such as the Cor nell Medical Index or the EPIC Health Question naire (12) provides a broad overview of health status. The questionnaire is reviewed by the eval uator to identify problems that may underlie per formance in the testing situation.

5. Perceived functional limits test-Whereas most of the critical job tasks have been identified by interaction between the treating physician and evaluator, it is necessary to screen for tasks that have been missed through the use of a test of perceived functional limits. The Spinal Function Sort and Hand Function Sort are used effectively to perform this task (Figs. 13.1 and 13.2). 6. Screening examination-Depending on the eval uee, his or her impairment, and the specific demands of the job, pre-evaluation screening should review active or passive range of motion, sensibility, muscular spasm, local swelling, cog nitive function, resting blood pressure and heart rate, or other pertinent musculoskeletal, neuro logic, or physiologic [unction. 7.

Progressive functional testing-A protocol based on progressive functional testing of the evaluee's ability to perform critical job tasks is designed based on the physical demands job analysis, physician's prophylactic restrictions, evaluee's health, evaluee's perception of his or her limits,


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Pre-Placement Screening

Figure 13.1 Spi nal [u nction sort-carry i n g a 3 0 - l b bucket 30 feel. W i t h perm i ss i on from Matheson L, M atheson, M. Spinal Function Sort. W i l dwood, MO: Employment Poten t i al Improvement Corpo ration, 1989.

Pre-placement screening has attracted substantial attention from employers in recent years because of its value in assisting employers to maintain a cost effective work force by assuring that workers are selected who are likely to perform job tasks in a safe and productive manner. The Americans with Dis abilities Act allows pre-placement screening as long as it is job-related, conducted after a conditional offer of employment is made to the applicant, is uni versally applied, is a valid indicator of essential func tion, and is a business necessity. Pre-placement screening is conducted by prop erly trained evaluators who use simulations of essential work demands that are content-valid or validated performance tests that have been statisti cally demonstrated to predict performance in these work simulations. Pre-placement screening is conducted using a pro tocol based on a physical demands job analysis. A content-valid test is used or a testing protocol is devel oped and a validation study conducted to demon strate that the protocol is statistically related to the essential job demands. A scientific validation study is necessary to objectively establish the statistical relationship between test demands and essential job

and the results of the screening examination. The most conservative of these parameters is used as a performance target and may be exceeded only with the utmost consideration given to the evaluee's safety. 8.

Next-day follow-up-A telephone or in-person follow-up must be conducted the day after the evaluation to elicit the evaluee's symptomatic response to the activity of the examination. This becomes a formal record that is added to the evaluee's file. This addresses the evaluee's readi ness to return to work.

9. Report preparation-The evaluator prepares a formal report that describes the Fitness for Duty Evaluation. This report is maintained in the confidential file. A synopsis that includes recommendations for the employee, employer, and treating physician is excerpted and pro vided to the employer for distribution. If the evaluation results in a recommendation against returning to the previous employment, reason able accommodation options must then be addressed. If viable options do not exist or are insufficient, the evaluator must provide ratio nale for a recommendation of no return to employment.

Figure 13.2 Hand function sort-pi c k out one l arge paper c l i p fyom a group of small paper c l i ps. With permission fyom Matheson L, Matheson M, Grant J. Hand Function Sort. W i l dwood, MO: Employment Potential I mprovement Corporation, 1 995.

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demands. Additionally, the validation study sets standards that minimize disparate impact for identi fied groups, including, but not limited to, individuals with disabilities, minority groups, females, and older workers. The validation study is conducted by a team that is composed of professionals such as an industrial psychologist, physiologist, ergonomist, and job ana lyst. Additionally, with proper training, an occupa tional therapist, physical therapist, or vocational evaluator can provide a validation study.

Development of Testing Procedures Employee selection procedures must be developed within the context of the Uniform Guidelines on Employee Selection Procedures (18). The Guidelines provide several important definitions. These include: Selection procedure-Any standard that is used as a basis for any employment decision is consid ered a selection procedure. The exact quote from the Uniform Guidelines is:

ate. Generally speaking, this means that the test bears an easily observable relationship to neces sary job demands. 2.

3. Development of selection procedures-Although the employer may utilize a standard "off the shelf" selection procedure, the employer has the burden of demonstrating the relevance of that test procedure to the particular circumstance. It is often less troublesome to develop a selection procedure specifically based on the employer's situation. 4.

. . . any measure, combination of measures, or pro cedure used as a basis for any employment dec ision. Selection procedures i nclude the ful l range of assess ment tec h n i ques from t ra d i t ional paper and pen c i l tests, performance tests, training progra ms or pro bationary periods, and phys i cal , educat iona l , and work experience requi rement t h rough i n formal or casual i n terviews and unscored app li c a t i o n forms. ( 1 2 [page 2 1 5 ] )

Adverse impact-There is no adverse impact if the worst performing group is achieving at a rate 80% as well as the best performing group, the groups defined as blacks, Native Americans, Asians, Hispanics, females, and males. Adverse impact is usually based on review of the mix of employees who are success fully hired. That is, it is not usually a question of one or another selection criterion, but the selection process as a whole. Content validity-This has to do with the con cept that the test is a "piece of the job." As such, the test may be considered content valid. Content validity cannot be used for issues such as person ality or intelligence but can be used when the test sample focuses on the necessary knowledge, skill, or ability to successfully complete the job. The EPIC Lift Capacity Test (30,21) can be used as a content-valid test. The Uniform Guidelines list these nine factors that must be considered in the use of a content valid test: 1.

Appropriateness of content validity studies-If a test is a representative and fair sample of job tasks or demands, it will be considered appropri-

Job analysis for content validity-A formal job analysis that identifies important work behaviors must be conducted. The job analysis must demonstrate that the worker characteristics are necessary for successful job performance.

Standards for demonstrating content validity The test user must demonstrate that behavior measured in the test constitutes a representative and fair sample of that which is required to suc cessfully perform the job and that the knowl edge, skill, and ability that is measured is that which is minimally necessary for successful job performance and that the test actually measures these factors.

5. Reliability-One of the advantages of the con tent valid approach is that validation tests based on statistical significance are not necessary. However, the Uniform Guidelines require that "whenever feasible, appropriate statistical esti mates should be made of the reliability of the selection." 6. Previous training or experience-This simply has to do with the need for the employer to demon strate that any requirement for previous training or experience is justified by demonstrating the relationship between this experience and the content of the job. 7.

Content validity of training success-This has to do with the use of a training program as a selec tion device and simply means that the content of the training program must be demonstrated to have relationship to the content of the job.

8.

Operational use-The selection device must be a measure of usual and customary duties.

9. Ranking based on content validity studies Uniform guidelines require that employers not use a ranking system unless the ranking system can be demonstrated to relate to job perfor mance. That is, if a ranking system is used, higher-ranked employees must be shown to do better in terms of job performance than lower ranked employees.


Screening by Health Care Professionals

Pre-placement screening that is performed by health care professionals will usually be based on content validity using a careful and weIl-documented job analysis to establish the business necessity of the test. The business necessity defense rests on five issues: 1.

The examination, test, or procedure on which the employment decision is based is found to be job-related.

2.

The examination, test, or procedure has a high predictive value and is the most accurate test that is feasible to use. This will often not be pos sible to establish initially and will require a lon gitudinal study if the employer is to have confidence that a subsequent EEO action will be defensible. Reliance on a cross-sectional study is to be discouraged in that if adverse impact is already current, the cross-sectional study will be confounded.

3. The examination, test, or procedure indicates that the applicant has a strong likelihood for the development of a serious injury or illness in the foreseeable future and the likelihood of injury or illness represents a significant variation from the general worker population, or discriminates effectively between individuals of varying degrees of productivity. Because the former, hav ing to do with job safety, is so difficult to estab lish, the latter, having to do with job competency, is more frequently used. When a test is being used to predict successful job performance, the length of time that is required to pass before the individual is judged to have been successful or unsuccessful on the job is finite and predictable. However, when the test is being used to screen for potential injury, considerably more time must pass before an individual is judged to be free fl-om injury. This length of time is open to wide variance and interpretation. 4.

The disqualification or other adverse personnel action is based on an individualized determina tion of fitness. Use of a simple cutpoint is not acceptable. This requires that each personnel decision involve a multifaceted review of the employee. Professional judgment must be exercised.

5. No reasonable accommodation will permit the disabled individual to perform the necessary job function. If the applicant qualifies as a disabled individual, the employer must be prepared to demonstrate that reasonable accommodation is not possible and/or sufficient. This, of course,

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does not hold when the applicant does not qual ify as a handicapped individual.

Role of the Treating Physician

The treating physician should be aware of predictors of back injuries and recurrence once the individual was employed. Even though there is no evidence that back strength alone is a predictor of back injury, there remains the question as to the role of diminished back strength in recurrence of back pain. In a recent study we investigated the role of strength training to reduce incidence of back injury in an industrial setting (36). The strip mining company had an average 9-year his tory of 2.94 injuries per 200,000 employee hours. This was devastating with their insurance rates. They initi ated a once per week back-strengthening program. The participants in the program were asked to volun teer. Eventually approximately half of the 400 employ ees volunteered. Ninety percent (90%) of those who did volunteer stated that they had some history of back problems, although they had no current workers' compensation claims. After the 20-week lumbar extensor strengthening program, they increased their strength an average of 54% in flexion and an average of 104% in extension. At the I -year follow-up, those who did not partici pate in the once per week 5-minute exercise program had an incidence of injuries of 2.55 per 200,000 employee hours, whereas those who did participate had one short injury, which came out to 0.52 injuries per 200,000 employee hours. The insurance liability dropped precipitously. A more recent study using similar back strength ening protocols in the airline industry demonstrated similar results (11). In this report, 622 participants in the exercise group were compared to a non-exercise group of 2,937. The back injuries in the exercise group analyzed were 5.7 per year and non-exercise group were 179 per year. Put another way, there were nine injuries per 1,000 in the exercise group, and 61 per 1,000 in the non-exercise group. The cost of back injuries in the exercise group was $206 participants per year, whereas the cost of back injuries in the non exercising group was $4,883 for non-participants. The exercises were once per week lumbar extensor strengthening for 5 minutes on MedX equipment, which isolates the appropriate muscles (Fig. 13.3). Obviously it is apparent that there is a relationship between strength and back injury prevention. Thus, a rational treatment program has been developed by several preferred provider organizations in the Southern California area (Table 13.1). One aspect of the treating physician's role is to encourage speed of initiating appropriate treatment.

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Figure 13.3 MecIX Lumbar Extension Machi ne.

Of course many doctors interweave decisions as to how rapidly a person can resolve their back problem and how long they remain on disability with how soon they get to see the patient. A recent extensive study by McIntosh et a1. has tried to clarify the pre dictive issues (34). In this study, 2,007 workers in

Table 1 3. 1 •

•

•

•

•

•

•

•

Ontario were analyzed from onset of claim to 1 year after the accident. Prolonged disability and delay in return to work was found to be predicted by several factors. Three or more positive Waddell signs and pain referral to the leg were physical examination predictors. Older age groups and working in the con struction industry were also predictors of prolonged disability. Interestingly, however, one of the most significant predictors was lag time from injury to treatment initiation. Even though it is recognized that many back problems are self-limiting, initiation of an active program certainly can place the patient into a framework of being able to control his pain. Along with the recurrence history, duration of cur rent symptoms increases the fear that the problem will not resolve. A recent study clearly documents the psychological barriers to an affective active treatment program (28). Marras et a1. performed a fascinating study on normal subjects, which has significant implications concerning the respect of for psychological barriers necessary in evaluating the efficacy of an active exer cise program in its potential to return workers to the workplace. In this particular study, students were being tested as to lifting performance under very spe cific evaluation conditions. Their muscle activity, spinal range, and speed were evaluated by special ized testing. Two tests were performed. The first test the students were encouraged and supported in their exercise. On the second round of tests, the students

Treatment of Medical Back Problems

A program of progressive exercise should be initiated after no more than 2 to 3 days of bed rest. Passive methods (either ice or hot packs) are only useful as an adjunct to exercise. Other techniques are not appropriate. An objective, reproducible functional assessment should occur if more than 2 weeks of treatment are required. Most patients need instruction on appropriate exercise but do not need a formal program of physical therapy. When physical therapy is indicated, duration should not exceed 6 weeks and frequency should not exceed three treatments weekly. Diagnostic radiographs are seldom appropriate initially and, with rare exceptions, are not appropriate at intervals during treatment. Unless neurologic function has deteriorated or progressive exercise has failed, specific diagnostic tech niques (e.g., CT scan, magnetic resonance imaging, bone scan, EMG, nerve conduction studies) are not appropriate. More than 7% of employed patients with medical back problems return to work within 4 weeks of onset. Careful re-evaluation of the treatment plan is warranted if the patient has not progressed significantly in 4 weeks. If treatment lasts 6 weeks, the patient should be evaluated by an appropriate medical specialist. The eval uation should include objective measurement of functional status, reassessment of treatment goals, and confirmation of appropriateness of treatment. If the patient has not returned to work within 3 months, the patient should be referred to a specialized center for computerized reassessment and care planning.


were criticized and psychologically stressed. All the students were psychologically tested before the lift ing tests. It turns out that those who on testing earlier were introverts showed significantly more co activity of muscle [·unction and thus had additional spinal loading compared to the extroverts who did not internalize the criticisms and lifted more effi ciently. These findings may explain why people with psychological barriers, such as demonstrated with positive Waddell findings in the McIntosh study, have delay in returning to work. Few treatment programs have expert psycholo gists and psychotherapists associated with them. Although certainly it would be an asset, that addition greatly increases the costs and certainly is not appro priate for every chronic and subacute patient. Gen erally, programs that have a comprehensive physical, as well as psychological, approach to management of chronic musculoskeletal problems are known as ter tiary care centers. They may have an inpatient com ponent to create an environment that is conducive to controlling psychological factors. The simpler alternative for treating individuals with fear, anxiety, and insecurity is the recognition that providing objective unbiased feedback of per f01-mance is an asset to treating their anxiety. Thus, treatment programs that use specific equipment, which can measure performance such as resistance training, offer a concrete maneuver to assist patients in recognizing that they can take control of their chronic pain problems. This equipment at least will provide feedback baselines in terms of range of motion, amount of resistance being used, and num ber of repetitions. By scoring performance on each occasion, the individual can document their progress without any extraneous factors. In addition, with the use of equipment that isolates various muscle groups and joints, the extraneous muscle activity, again noticed in the Marras study, can be blocked out to allow more efficient effective exercise programs. This can docu ment progress in a measurable manner. Thus, the treating physician has the responsibility to keep focused on objective measures of improving performance and the rate of improvement. If the treatment program plateaus, then some change has to occur. Here the individual is ranked as having reached maximum medical improvement or another strategy has to be initiated. This strategy might be injection procedures, consideration of surgical inter vention, or a complete change in format for the treat ment program. Although the treating physician generally does not control the physical treatment program being per formed by physical therapists and exercise science people, he/she must expect these treatment programs to offer sufficient information on which to make a

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judgment as to progress or alternative strategies. The report must be crisp and offer sufficient information on which to make judgments. It should give informa tion that would assist the treating physician or the evaluating physician criteria on which to make judg ments in terms of function. It also should include total number of visits, the type of treatment, and the subjective and objective findings. Finally, a brief note as to assessment and future plans should be available. An example of such a report is in Figure 1 3.4. A recent study clearly documents the role of objec tive testing in modifying physical therapy practice (9). This study notes the change in physical therapy practice after the State Labor Commission in Utah requested a report from therapists before more treat ment would be authorized. After every six visits, a report identifying changes in at least three essential physical functions, such as lifting, carrying, range of motion, sitting tolerance, etc., was requested. If no improvement is noted, restorative services will not be continued to be authorized. There were approxi mately 30,000 claims in 1997 and approximately 33,000 claims in ] 999 after the initiation of the new report form. Associated with the institution of this form, the frequency of treatments decreased 34% from 17 in 1997 to 1 1 .4 in 1999. Hot pack usage decreased 45%, electrical stimulation decreased 22%, and massage decreased 38%. However, therapeutic

Spine & Sport™ Functional Capacity Evaluation Summary Page

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Pati nt :

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The m/ormatlon cont.. i mus and medius m uscles. For example, to facil itate the gluteus maximus, the base of the tape is first applied on its proximal attachment on the poste rior i l ium and then anchored on the greater trochanter after the hip is taken through the maximum pain-free flexion range of motion.

Kinesiotaping in the Treatment of Upper Crossed Syndrome

Figure 26A.2 Taping [or fac i l i tating gluteus maximus

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that are often shortened are the pectora l i s major, upper trapezius, and l evator scapu lae, whereas the muscles that are often inhibited or weakened are the deep cervical flexors and m i d and lower trapezius. I n addition t o posture retra i n i ng a n d stretching of the shortened m uscles, ki nesiotaping m ay be used to faci litate the postural awareness of the pat ient ( Fig. 26A.3) and i nhibiting the overactive m uscles. For postural tapi ng, the scapul a is first posi tioned in neu tral as much as possible. The base of the tape is first applied anterior to the acro miocl avicular joint and then p laced over the scapula in the direction of the i n ferior angle and thoracic spine. To inhibit the upper trapezius ( Fig. 26A.4), t he base of the tape is first applied at the lateral border of the acro m i u m and t hen placed along the muscle bell y to the base of the occiput, whereas the cervical spine is side-bent and rotated away.

• CONCLU SION

Although the exact mechanisms by which propriocep tive taping is e ffective are unclear, i ts clinical e ffects are significant and i m mediate, especially in relieving pain, promoting altered movement patterns, and allowing earlier progression of rehabil itation. Taping, in conjunction with manual therapy, therapeutic exer cises, and patient educati o n , is a use fu l adj unct in treating muscle i mbalances and i mpaired movement patterns.

The posture in the upper crossed syndrome ( 7 ) is often exhibi ted i n a push - forward posi tion of the head and rounded shou lders, causing mechanical strain on the cervical segments and associated m us culature necessary to support the head . The muscles

and gluteus med ius.

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Figure 26A.3 Taping for postural support.

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Part Five: Recovery Care Management (after 4 weeks)

Figure 26A.4 Tap i ng [or upper trapez ius i n h ibi t ion.

• REFERENCES I . Bullock-Saxton J E, Janda V, Bullock Ml. Renex activa tion of gluteal muscles in walk i ng with balance shoes: an approach to restoration of function for chronic low back pai n pat ients. Spine 1 993; 1 8 :704-708.

2. B u l lock-Saxton J E . Local sensation changes and altered hip muscle function fol low i ng repeti tive ankle spra i n . Phys Ther 1 994;74( I ): 1 7-3 1 . 3 . B u l lock-Saxton JE. The i n n uence of ankle sprain on muscle recruitment duri ng hip extension. I nt J Sports Med 1 994; 1 5 :330-334. 4. Cerny K. Vastus medialis obl i ques/vastus lateralis muscle activity ratios [or selected exercises i n per sons with or wi thout patellofemoral pain syndrome. Phys Ther 1 995;6: 672-683. 5 . G i l leard W, McConnell J , Parsons S. The effects or patellar taping on the onset of vastus medialis obl iquus and vastus lateralis muscle activity i n per sons with patello[emoral pai n . Phys Ther 1 988;78: 25-3 2 . 6. Janda V. M uscles, central nervous motor regu lation and back problems. I n : Korr M, ed. Neurobiologic mechanisms in manipulative therapy. New York: Plenum Press, 1 986:27-4 1 . 7 . Janda V. M uscles a nd cervicogenic pain syn dromes. I n : Gra n t R, ed. Physical Therapy of the Cervical and Thoracic Sp.i ne: Cl i n ics in Physical Therapy. N ew York: C h u rc h i l l - Livi ngstone, 1 988: 1 5 3 - 1 66. 8 . J u l l G, Janda V. M uscles and motor con trol in low back pai n . I n : Twomey LT, ed. Physical Therapy [or the low back : C l i nics i n Physical Therapy. New York: Church i ll-Livi ngstone, 1 987. 9. Kase, K. Ill ustrated Kineslio Tapi ng, 3rd ed. Tokyo: Ken'! Kai, 1 994. 1 0. Kase K, Taksuyuki H, Tomoki O. Ki nesio Perfect Taping Manual. Albuquerque, N M : U niversal Pri nt ing & Publishi ng, I nc, 1 996. I I . Lephart SM, et al. The role of proprioception i n t he managemen t and rehab i l i tation of athletic i njuries. Am J Sports Med 1 997;25 : 1 30- 1 3 7 .

Global Muscle Stabilization Training Isotonic Protocols

Neil Osborne and Jonathan Cook

Introduction Origins Major Influences

Considerations in Successful Isotonic Training Key Factors for Successful Isotonic Training

Learning Objectives

After reading this chapter, you should be able to: •

•

Advantages of an Isotonic Program What and How to Train

The Model Three-Stage Approach

•

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Patient Selection and Assessment Achieving Compliance Exclusion Criteria Assessment Concurrent Passive Care

Post-Isotonic Program Reassessment Cases

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•

•

Understand the principles u nderp i n n i ng i sotonic t rain i ng i n reh ab i l i tation B e conversant with the l iterature perta i n i ng to i sotonic t ra i ni ng protocol s Outl i n e key elements i n t h e design of successf u l isotonic tra i n i ng U n derstand how and when isotonic trai n i ng may be i ncorporated i n to the m otor control (stab i l i za tion) model o f spinal rehabi l i tation Define normal parameters in strengt h , endu rance, a n d rat ios of t h e spi nal muscu latu re. Devise an assessment strategy for t h e rehabi l i ta tion candidate requ i ri ng isotonic t ra i n i ng Select appropriate exercises for an i nd ividual's particular req u i rements

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Introduction Origins

The a i m o f this c hapter is to describe the devel op ment, rational e , and detail o f a g lobal spinal stabi l i zation rehabil i tation model curre n tly in use a t t h e Anglo-European College of C h i ropract i c (AECC). This particular brand of rehabilitation is consistent with the contemporary trend toward patient-centred active care (17,4 3 , 51 ,54 ) and derived from a number o f i n fl ue nces, many o f wh i c h are described in detail throughout this book. However, the catalyst for the de velopment of such a program came from the AECC's MSc Program , developed in response to a demand From the profession for a formal i zed, post-graduate, u niversity-validated Master's degree, the rational e for which has been previously described ( 8 ) . A large componen t of t h e M S c C l i nical C h i roprac tic was spinal rehabil i tation. Students were exposed to a number of models, many of which were described by con tributors to this book and its predecessor, i nclud i ng Vladamir Janda, Karel Lewit, Craig Liebenson, Howard Vernon, and Alan Jordan . The aut hors of AECC's approach , and of this c hap ter, have reviewed the l i terature u nderp i n n i ng the described models and have i ntegrated the emerging issues. The model is heavily based i n the l i terature, objectively moni tored w i t h validated outcome tools (see chapters 8 and 11 ), and is con t i n ually u n dergoi ng critical review.

Major Influen ces

Perhaps the most signi ficant underpinning concept of the program is the promotion of "correct fornl ." In this there must be an appreciation of the "decondition i ng syndrome" (see C hapters 1 , 2 , 5 , 2 5 , and 2 6 ) and pro motion of local and global stabili zation procedures.

Local Stabilization L ocal stab i l i zation is the promotion of key muscle group activity at a l ocal segmen tal l evel ( w i t h i n the l ow bac k or nec k ) . The goal i s to ensure good local stabil ity before addressing the deconditioned global musculature. The most convi nci ng spinal work to devel o p in this area has been performed by a team o f Australian researc hers who began by n ot i ng a m arked l ocal segmen tal atrophy of m u ltifidus i n the l umbar spine secondary to acute l ow back pai n . They went on to observe conti nued de-stabil ization o f the l umbar spine resulting [To m the transverse abdomi n us i n h i b i t i o n a n d t h e n began developing a protocol t o restore the functional cocontraction of these muscl es as seen

i n healt hy i ndividuals (19-2 1 ,2 3-2 5 ) . Adequate co contraction is described as a prerequisite to lumbar spine stability ( 21 , 24, 2 5 ) and has been shown to sta b i l i ze the sacroiliac joi n t (48 ) . The trai n i ng i nvolves isometric cocontraction of the m u l t i fidus and trans verses abdom i n us and then the superim posed train ing of global muscles, through which the i nd ividual learns to resist destabilizi ng load to the spine. A par allel exercise has also been developed [or the cervical spi ne. In t hemselves such stabi l i zation exercises do not seem to i ncrease the size of the paravertebral mus cles, when measured with compu terized tomography, and other stre ngth en i ng exerc ises need to be added to the program . Simple dynamic ( isotonic) and stat ic dynamic (stabilization) exercises have been shown to be equally effective in t h is respect ( 1 1 ) . Th is appare n t ly s i m p l e co-co nt raction exercise and i ts cervical spine equivalent, cervico-cranial flex i o n : , are described in c hapter 2 5 . M cGill, however, describes, i n h is excellent book on the subject (42 ) , the l i m i tations of purely prescribing transverse abdominus activity as a prerequisite to ex ercise. He argues t hat the work that has come out of Austral i a (19,20,23,24 , 2 5 ) has lead to some confusion in the l i terature, as it is being i n terpreted as an ade quate prerequisite to isotonic or stabil i z i ng exercises. Whereas he agrees that the work is very usef'ul be cause it has identified abelTan t motor con trol patterns i n patients w i t h l ow back pai n and can be used to re-educate this motor control pattern, McGil l argues that, as a core stabilizi ng exercise, it is inadequate. I n electromyography studies, McGill a n d coworkers (31) have compared muscle activity of the l ow back and presented a sensible and convincing argument t hat braci ng is superior to si mply promoting transverse abdominus activity ( 3 1 ,4 1 ,42 ) . He argues that the "sta b il i ty i n dex" for the low back, because of the bracing exercise, is vastly superior to abdomi nal hollowi ng and affords greater low back protection. The argu ment is, perhaps, flawed i n one respect; in that he equates the "gross" abdominal holl owing to t he spe cific isolation of the transverse abdom inus, which has been promoted by the Australian workers (19,20,23, 24 , 2 5 ) . Not withstandi ng, the message that braci ng, rather than transverse abdomi nus activity alone, needs to be a prerequisite is clear. The model that has been adopted by the authors of t h i s chapter i s that the transverse abdominus is i solated as described by Richardson and coworkers (19,20,23- 2 5 ) to ensure activation of mul t i fidus, and is then fol l owed by a braci n g procedure, before any subsequent exercise. At AECC, all patients are educated to exercise with well-control led posture, l ocal s tabil i ty ( t h rough co con traction or cervicocranial flexion), and controlled breath i ng. The mastery of t h i s is a prerequisite to

Chapter Twenty-Seven: Global Muscle Stabilization Training-Isotonic Protocols

other exercises and the promotion of "good [ orm" is a strictly observed pri nciple. I n teresti ngly, Joseph Pila tes, a boxer and German national in terned in E ngland during World War 1, developed the " Pi lates tech nique." H e devised a set of exerci ses that "made sense" to him and the promo tion of a "navel-to-spi ne" pol icy before exercise has been prac ti ced by interested individuals ever si nce. Pilates is has a much less refined, albe it remarkably si mi lar, pr i nci ple and h as sign ificant overlap wi t h t h e establishment of w h a t is n o w understood to pro mote "local" or "core" segmental stabi li ty.

Global Stabilization Global stabi li zation i nvolves the promotion of mus cular stabi li zation t hrough t he trai n i ng of m u l ti segmental muscles. T h e l i terature is r e p l e te w i t h articles detai l i ng t h e effectiveness o f regional strength and endurance tr ai ning, with perhaps the most rele vant reviews of this wor k conducted in 1 995 and again i n 1 996 by Jordan and Maniche (26,36), who con cluded that such aspects as dose, i n termediate and l ong-term goal sett i ng, and supervision of patients are among the factors most l i kely to yield benefi t . The vigorous approach taken with the patient with low back pain ai ms to redress the balance of decondition i ng and fits wel l wi th the observation that the strongest physical predictor f or c hronici ty seems to be l umbar extensor stami na (7,26,32, 3 6 ) . T o combine t h e two pr i nciples, i . e . , t o perf orm t h e isome tric local stabi l i zation exercises before a n d dur i ng al l further vigorous isoton ic exercise is central to AE CC's approach to rehabi li tation. The u l ti mate goal (albei t per haps on occasi on i mpossible to achieve) is not to al low the patients to move onto global stabi l i ty/isotonic trai n i ng u n t i l they c a n satisfactorily act i vate the local stabi l i zers. Furthermore, it is hoped that this local stabi lity pro motion will become "automatic" t hr ough repeti tion, the promotion of "form," and the use of sensory motor trai ning procedures (see chapters 22, 25, and 26).

Considerations in Successful Isotonic Training E xercises have been advocated for spinal pain for more t han 1 00 years. Various m u l t idiscipli nary pro grams have been designed and studied, but t he major ity of cli nical tr ials i nvestigating the ef fects of exercise i n tervention for low back and neck conditions h ave i nvolved isotonic traini ng. There is more evidence and l i terature regard i ng this form of spinal rehabili tation than any other (2,3,7, 1 5 ,22,26, 2 8,36,37,4 5 ) .

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The li terature ci ted wi t h i n t h i s section is n o t i n tended to b e exhaustive, but rather i s i n tended to pre sent t h e m a i n argu m e n ts u nder pi n ni ng t h e model descri bed.

Key Factors for Su ccessfu l Isotonic Trai ning

As with other f orms of rehabilitation, the main aims are the restoration of functional capaci ty by Faci li tat i ng heali n g processes ( treatment) and t he strength e n i ng o f weakened t issues ( prophylaxis). I sotonic strength and endurance training has several physio logical and psychological benefi ts ( 26, 36). •

Muscle strength gai ns

•

Strengthened connective tissues

•

Neurophysiologi cal i mprovements

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I mproved capi l l ary b lood perfusion to muscle

•

I mproved discal nutri tion

•

Increased bone miner a l con tent

•

I mproved physical condition

•

I ncreased production o f endogenous opioids

•

Positive psychological elements

Reviewi ng the trials using isoton ic tra i n i ng, there are conf l icting conclusions in term s of pai n , disab i l i ty, a nd function regardi ng t h e ou tcomes of such pr o grams. Consequently, in an attempt to make sense of t hese apparen tly contradi ctory conclusions, Jordan and M an niche began a nalyz i ng the published trials to i dentify what the successful tr ials had that the less successf u l l ac ked ( 2 6, 3 6 ) . Despi te considerable i nvestigat ion i n t h e area, the ideal trai ning program has not yet been (and may never be) identified, because studies compari ng one type of exercise to another are sparse and i nconcl usive. However, the conclusions of Jordan and Manniche's provide essential, evidence-based guideli nes for t he design of a success[- u l i so to ni c progra m , such that the condi t ions for effective trai ni ng may be spec i fi ed . These condi tions i nclude dosage, d uration, relative d isregard for pai n , and supervision and com pliance.

Dosage Ef fective train i ng requires sufficient dosage. Research i n low back and neck training suggests that most ben e fi t occurs wi th a greater amoun t of exercise and an i ncreasi ng number o[ repetitions ( 2 , 1 5,2 2,30,4 5 ) . E ndurance training is pr i marily tar geted i n an iso tonic program, at least in the i ni tial stages. E ndurance loading maximizes blood flow, thereby max i m i zing

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heal i ng. Fu rthermore, emphasizing i mprovements i n the tonic holding capaci ty (endu rance) o f t h e spi nal stabi l i zers is in keeping with most schools of thought in spi nal rehabili tation . Endurance is typically trained in the decond itioned pat ient with load i ng at 30% to 4 0% maximum vol u n tary con tracL io n ( MVC) and performing three sets of 1 2 to 14 repetitions. I t is suggested that spinal muscu l atu re endurance levels wil l i n c rease by 1 00 to 1 50% w i t h i n 8 weeks i n typical decondi tioned i ndi viduals (3, 2 8, 3 7 ) . F o r t hose p a t i e n ts w hose occu pa t i o ns or activi ties i nvolve abnormally h ig h l evel s of spinal loading (e.g . , athl etes, heavy l abourers) , add i tional protec tion to the spine may be provided through i ncreased strength. Strength tra i n i n g requ i res l oads of 70% to 80% MVC, performing one to two sets of 8 to 1 2 rep e t i t ions. Maximal strength gai ns after 8 weeks w i l l be approximately 25% to 4 0% ( 3, 2 8 , 3 7 ) . However, the development of strength is u sually a secondary con sideraLion. Clearly, in su c h cases carefu l considera tion needs to be given to muscle i m balances and the promotion o f core stabi l i ty.

Duration Meani ngfu l resu l ts have been obtained for the spine i n terms of du ration of exercise programs, suggest i n g that reasonable st re ngth gai n s and su bjective i m provement occur w i t h super'v ised training for a m i n imu m of 8 weeks, w i t h two to t h ree sessions per week ( 2,3,6,29, 3 0 , 3 7 ) . The du rati o n of the sessio n shou ld n o t exceed 1 hou r. The period of t ra i n i ng may be increased for post operative patients (e.g., d isc surgery) , w i t h the length of trai n i ng for su ch patients reach i n g as muc h as 3 to 4 months ( 3 8 ) . T h e tra i n i ng sessions s hou l d b e h i g h i ntensity. Tri als l ooking specifically at the di fferences in ou tcome between h igh- and low-i ntensity programs demon strate su peri or benefits f Tom high-intensity exercise (3,6, 1 5 , 1 6,22,29,30,37).

case needs to be judged on the individual's pain toler ance and fear-avoidance behavior. There may be several clinical exceptions to the "dis regard of pain" concept, which are beyond the scope of t h i s chapter; however, a notable example wou l d be perip heral i zation of pain ( M cKenzie concept) (see C hapter 1 5 ) .

Supervision a n d Compliance Compliance is perhaps the si ngle most im portant and predic tive issue in the program. Some early attempts at reh abi l i tation programs reported drop-out rates as h i gh as 5 0% to 70% ( 1 4 ), l argely because of fac tors other than a worsening of sym ptoms. More re cently, i t has been suggested that comorbidity and an expectation of barriers to com plet i ng a program leads to less l i ke l ihood of compliance (4) . I deally, tra i n i ng shou l d be performed in a su per vised setting. Although t here will be i nevitable thera peu tics gains, u n su pervised exercise programs lack accou n tabil i ty of form and compl iance, and progres sion cannot be as effectively moni tored; consequently, drop-ou t rates are h igh. In 1 989, Rei l ly and L ovejoy (46 ) observed 9 1 % compliance to a su pervised pro gram compared to 3 1 % i n an ident ical program i n which the patients were not su pervised. As a resu l t, at 6 months the supervised grou p showed sign i ficantly greater improvements in aerobic fi tness, strength , and pain. Suc h a finding has been echoed by other studies (40 ) . There is also a case for prescribi ng addit ional un su pervised daily home exercises on the days when formal tra i n i ng does not take place. This may ass ist in redu c i ng dependency and encouragi ng sel f-help. However, the balance of evidence clearly em phasizes the importance of su pervised tra i n i ng. The com prehensive l i teratu re analysis of Jordan and M a n ni c he's ( 26, 36) suggests that small cohorts of ideally fou r to five patien ts are most benefi c i a l , because patients i n suc h set t ings tend t o become mu tu a l l y supportive. Instruc tors should be " i nspir i ng, creative, and always strivi ng to lead pat ients away f rom stereotypic pat ient roles."

Relative Disregard of Pain To max i m i se psychological benefits, i t is i mportant that pai n is not the main i ndicator in setti ng dosages and perform ing the exercises. Focus shou l d be placed on restoring fu nctional capacity and understand i ng that pain i mprovements w i l l tend to occur gradu a l ly and as a secondary effect. If the approach becomes "let pain be you r gui de," the program is less l i kely to be less successfu l (l), and therefore posi tive rei nforce ment that "hurt" does not necessarily equal "harm" is recom mended. Caution is recommended and each

Advantages of an Isoton i c Program

With stu dies advocat i ng various forms of spinal re h ab il i tative tra i n ing, the c l i n i cian is lef t to choose which compbnents to i nclude in a program. The choice i nc ludes local stabi l i zation training, flexibi l i ty exerci ses, sensori motor stimu lation, aerobic fitness training, isotonic trai n i ng, and isometric (global IIIus cle) spinal stabi l i zation tracks. C l i n ical opi nion and research evidence purports benefits of eac h approach .


However, isoto nic trai n i ng programs h ave several obvious benefits: a) They use a standardised fTamework within which specific dosages and exercise mod i fications may be set fo r the i ndividual . This approach may be less tissue spec i fic but it is easier to apply i n no n specific musculoskeletal pai n. b) Goal set ting is simple and fu nctional progress is self-evident. Regularly achievi ng dosage goals has obvious physical benefits [o r the individual as wel l as bei ng a po tent psycho logical mo tivator. c) Isotonic exercises req uire a relatively low super visor to patient ratio. Once the patients master the relatively simple exercise procedures, they can beco me largely i ndependent. Other rehab i l i tative procedures such a s co-co n t ractio n o r iso metric spi nal stabi l i zatio n tracks (e.g., the Bridge exercises; see Chapters 25 and 2 6 ) require high levels o f precisio n , tu itio n , and mo n i to ri ng; there fore, they require ongo i ng i n tensive levels of o ne-to-one su pervision.

d) Outcome measures are easier to apply because each patient undergoes the same trai n i ng pro gram. A more tissue spec ific approach requires more variation in exercise procedures, making i t more d if ficult to co m pare l i ke w i t h l i ke .

What and How to Train

Many studies have identi fied the l i n k between spinal pain and reduced strength, specifically e ndurance of the spinal stabi l i zers. This evidence primari ly con cerns patients with chro n i c low back or n eck pai n . I n a study o f 9 1 2 adults, B ieri ng-Soerensen ( 7 ) identified the strong correlatio n between l um bar extensor weakness ( reduced endurance) and the l i ke l i hood of first-time low back pain developing. Patients with chronic low back pain were also shown to have poo r l umbar endurance co mpared to t hose w it hout, a finding strongly supported by the work of Luoto i n 1995 ( 3 5 ) . Furthermore, good isoto n i c endurance seems to pro tect agai nst occupatio nally related back pai n (50). However, such a static back endurance tes t , ar guably, beco mes a test or pa i n , ra ther than an endu rance test, i n those with low back pai n . Further, Rissanen (49) demonstrated a co mparative weakness of the low back flexors and extenso rs i n chronic low back pai n patients. The same fi n d i ng was derived f ro m a large-scale trial by Schifferdecker Hock et al (52), who also noted flexor/extensor weak ness in chronic neck pain patients. Jordan (28) showed a strong correlatio n between chro n i c neck pain and neck weakness co mpared to age-matched asy mpto -

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matic subj ects. Restoring, o r at least i m provi ng, strength and endurance in the neck o r low back has a sign i ficant i m pact o n c h ro nic pain, f u nc t io n , and disabi l i ty (6,7, 2 8, 3 5,43,45,4 9 ) . I n a study o f 5 94 people between ages 3 5 a n d 54 , Al aranta et al ( 2 ) attempted to establ ish no rmative static back e nd urance values and, a l t hough t h e i r res u l ts were further bro ken down i n to age ranges, o ccupation ( w h i te co l lar/blue co l l ar), and sex, the mean normative values for females ranged between 62 and 1 22 seco nds, and fo r males between 73 and 1 3 1 seco nds.

Ratio Promotion One key aspect i n t h e i m p l em e n tatio n of isoto nic train i n g exercises is attentio n to the resto ration of normal strength ratios. The relatio nsh i p in terms of maxim u m vol u ntary con tractio n between t h e flex o rs, extensors, and l ateral flexors is i nvariably dis rupted by i njury and/or chro n i c pai n i n the low back and neck ( 5 , 2 8 ) . Considering t h e neck i n asy mpto matic i nd ividuals, the ratio between extensor and flexor strength should be i n the region of 1. 7: 1 ( 2 8 ) ; and t h e relatio n s h i p of the l ateral flexors should be equal. The ratio in chro n i c neck p a i n patients tends to be approxi mately 1 : 1 ( 2 7 ,2 8 ), suggesting t hat whereas bo t h flexors and extensors weaken w i t h c h ro nic pai n , the greatest degree of weaken i ng is i n the extensors. The m a i n except io n to this ru le is in hyperexten sion i nj uries, in which the neck flexors u ndergo the greatest degree of weake n i ng. ConsequenL ly , dUli ng iso to n i c tra i n i ng, dosage and goal setti ng should be mod ified to restore the " normal ratio" while strength e n i ng each i nd ividual muscle group. The si tuation i s rather l ess predi c table i n the low back , but attempts at a calculat io n co nsider the nor mal strength ratio between extenso rs and flexo rs to be approximately 1 . 3 : 1 ( 5 , 2 7 , 2 8 ) . O nce aga i n , i n t h e c hron i c l o w b a c k pai n patient, the ratio tends to be approximate ly 1 : 1 . Therefore, dosage and goal set t i ng s hould once aga i n ref l ect restoratio n of the nor mal ratio .

Task-Specific Although the advantages of iso to nic, gy m-based pro grams are clear for the practi tioner because they are easy to i m p lement and generic exercises fo r several people can be prescribed, this can also be their down f a l l . There has been a lo ng-accepted pri n c i p l e i n sports rehabi l i tation (speci fic adaptation to i ncreased demand [ SA I D] ) that when returning to a particular sport af ter a period of recuperatio n , aspects of that

672

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Part Five: Recovery Care Management (after 4 \Neeks)

spor t should be carefu l ly i mplemen ted in to the pro gra m . For example, a j ave l i n thrower should have slow, controlled , j avel i n t h row-like exercises, w i t h we ight a n d pulley resistance w h i le adopt i ng a correct stance and using the tor so to generate force in the same way that they would i n their spor t . The program w i l l progress in terms of speed and force and gradu a l ly culmi nate in a " m i m icking" of t h e t h row. The same pr i nc i pl es should apply to all rehabi l i tation programs. So, for t h e low back, part of the assessment [or t h e patient should involve an ind ivid ual assessment o[ their activi ties of daily l i ving (ADL), especially t hose movements that produce pain , and their program should promote strengthening to ad dress t hese A DLs. T h i s approach i s referred to by some as wor k-harden ing.

tion s w i t h a pressure increase or approximately 8 to 1 0 m m Hg. For t hose patients who are unable to ach ieve these i deal standard s, t heir "best effort" is recorded and then observed throughout the program to en sure contin ued i m provement, or at least no worsening. On occasion we h ave w i tnessed pa t ients who achi eve l i tt l e or no competency in local muscle con t ract i o n , yet whose resul ts on completion of the iso tonic program are excell e n t . Notwithstand i ng, the i nterpretation of "best evidence" would suggest that as long as comp l i ance remains una ffected , core sta b i l i ty should be promoted ber ore global exercises. Once the patient is identified as a good cand idate [or the i n tensive 1 O-week program , referral to the pro gram is made.

The Model

Stage 2 - lsotonic Training

The pr ogram developed at AECC combines isoto n ic tra i n ing [or the global stabi l i zers with l ocal stabi l i zation traini ng, m uscle relaxation wor k , a n d sen sori motor stimulation. It is i mplemented i n three stages.

A fier assessm en t , t he patient w i l l t hen u ndergo a 1 O -week, twice weekly, supervised program, i n which most of the emphasis is on isotonic tra i n i ng. The basic procedure for endurance train i ng is descr ibed in Exer ci se 2 7- 1 . The exercises are descri bed in Exer c ises 27-2 to 27- 1 2 . All isotonic exerc ise are preceded w i t h co-con tr action and bracing.

Three-Stage Approach

Stage 1 Stage 1 is the transition [yom passive to active care with tec hniques, exercises, and advice to en h ance the patient's response to treatment , and to prepare the pa tient adequately for isotonic tra i n in g as n ecessary. I t theref ore i nvolves t h e progressi on alon g the conti nuum between passive and active and is i m plemen ted by the prac t i t ioner as part of the regul ar tr eatmen t sessions. Largely, i t i nvolves t h e promotion of home stretching exercises (chapters 1 9 and 24) and the i ntro duction of local stabi l ity exercises. The emerging evidence supports the concept that l ocal stab i l i zation should precede global stab i l i za tion ( 3 , 6 , 2 3 , 2 9,30,4 2 ) . Consequen tly, a formal assess ment of local s tab i l i zer [unction (co-con trac tion ) i n t h e low back and cervi co-cran ial fl exion i n t h e n eck (chapter 25) is also performed a t this early s tage. De ficits i n l ocal stab i l i zation are addressed through the i n i t iation of co-contraction or cervico-cranial flexion tra i n i n g on a da ily basis. In the case o[ transversus abdominus and m u l t i fid us co-contraction , i t is intended t h a t before train ing isotonical ly, the patient will be capable of passing the l evel 1 test (10 1 0-second m u l t i fidus contractions and the same transversus con tractions with pressure bio feedback reduction of approximately 6 to 1 0 m m Hg). For cervical reh abil i tation, the i deal standard on cer vico-cranial flexion testing is 1 0 1 0-second contrac-

Exercise 27-1 The Endurance Range A simple and effect ive approach to sell ing dosage in iso tonic resistance training, with weights, is to determine the level of resistance at which an individual can perform 3 sets of 1 2 repetitions ( i f they cannot perform this, then t h i s w i l l become the first goal). At su bsequent training sessions, t he ind ividual attempts to increase the number of repe t i tions unti l they attain 3 sets of 20 repeti tions. At t h i s point the resistance is increased (perhaps by only 5%) and t he dosage reverts back to 3 sets of 1 2 repeti t ions, and the process is repeated. The appl ication o f this principle in the isotonic rehabi l itation sett ing is worthy o f mer i t , even when the resis tance is body weigh t and cannot be changed, such as in dorsal raises. In t h is exam ple, 3 sets of 1 2 is the in i t ial goal, even t h ough an ind i vidual only may be able to perform 3 sets of 6 i n i t i a l l y . W i t h t i m e they shou ld be able to b u i ld to 3 sets of 1 2 and then to 3 sets of 20, adding small weights to their hands (as an advance ment) if necessary. All of the exercises described in the fol lowing Tables use t h is principle, descri bed by Mooney et a i . , ( 200 1 ) when setting doses. Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D. Exercise treatment for sacroiliac pain. Orthopedics 200 I ;24:29-32.


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6 73

Exercise 27-2 Angle Bench Dorsal Raises (Back Lifts)

Exercise 27-3 Abdominals (Curl Downs Plus Alternative) (Figs. 27.2 and 27.3)

The Procedure

The Procedure

The prone patient is placed with L4 over . t he center of

Seated, knees flexed to 90°, shoulders flexed to 90°.

the roller-"Navel over center of rol ler."

Perform co-contraction and hold.

They are then instructed to perform t he co-contraction and to maintain a regu lar breathing rate while elevating themselves into 5° of lu mbar extension. If they are to be assisted, then the supervisor assists by l i fting the patient's arms. Repet itions are performed at breat h ing rate w i t h hands beside head i n double-sided salu te posi t ion. Between each set they are advised to rest, crouch ing back on their haunches, w i t h the shoul ders dropped low, unt i l their heart ra te recovers.

Lower trunk over count of "3," trying to resist most d i f ficul t part Uust before shoulders touch down). Heels m us t N OT l eave floor. If unable to maintain heel contact , start w i t h feet further out and draw in du ring maneuver. Return to upright in a stra i g h t line using arms by sides-pressing, sym metrical ly off the floor. DO NOT hold patient's feet down. Digging heels into the floor accompanied by a posterior pelvic ti I t and co-contraction wi II fu rthel- de-f aci I i tate i l i opsoas.

Advancement

Hold ing free-we ight by forehead Dynamic/Static Option

Between each repe t i t i on, they hold for 5 seconds. Increasing 1 0 to 20 repetitions for a m ax i m u m of 3 sets. This seems to increase the cross-sectional area of m u l t i fidus more effect ively.

(coni inued)

6 74 -- Part Five: Recovery Care Management (after 4 weeks)

Exercise 27-3 Abdominals (Curl Downs Plus Alternative) (Figs. 27.2 and 27.3) (continued)

Exercise 2 7- 4 Leg Extensions Correct Procedure

Patient in reverse position, prone, on angle bench with greater trochanters at level of roller, and the bench angled down. Set bench two levels down from hori zontal . Canvas belt secures pat ient t o bench (diagonally across sacrum ) to help avoid use of arms ( Iats) in action. Knees remain completely extended throughout action. Try to maintain co-contraction t hroughout . Extend fTom straight leg fTom hips unt il legs i n straight l ine with torso. May help to tell patient to dorsiflex ankJes. DO NOT H Y P E R EXTE N D. Action performed slowly to avoid hyperextension.

Advancement

H old ing free-weight across the chest (albe i t unusual for anyone to achi eve this) Alternatives (to b e used if peel back required from curl-downs)

I ) F i l l er. Kneel ing in co-contraction, shoulders centered above trolley. Push down firmly and slide trolley from side to side maintaining shoulders centered above fitter ( NO T R U N K ROTATI O N ) . T h i s m u s t b e slow and control led.

2) Gym ball si t-ups. Co-contraction maintained throughout. Pelvis s i ts on h-ont of ball (not on top ) .

� ",�"" .... , I t '

···t· •

H ands across chest. L i m i t depth of curl-down t o 45° off horizonta l . Some patients can only do t h is with feet secured. This is not i deal because i t activates the i l i psoas but is on occasion unavoidable. 3) See chapters ( 5 and 26) for the low force approaches of Stuart M cG i l l .

H owever , a r ecent s tudy i nvestigating t h e effects o f l u m bar exlensor trai n i ng on c hanges i n t h e cross secL i onal area of the lumbar m u l ti fidus i n chronic low back pain patients suggests a slight modification of dorsal raises and leg rai ses to achi eve opti m u m re s u l ts ( 1 2 ) . The aut hors s howed that i n 1 0 weeks of train ing, signi ficant hyper trophy of the m u l t ifidus was achi evable usin g 5-second static holds belween the concentr ic and eccenlr ic phases of dorsal r a i ses and leg raises ( lhe quadruped exer ci se was also used) . I n leresl i ngly, t he s a m e exer cises w i t h o u t static holds and co-con traction-based exercises alone wer e

Alternatives

1. Single-leg raise. Action must come from gluteals and h ip, NOT from rotation of the torso.

2. Knees start in flexion and extend w i t h h ips 3. Double leg raises

(continued)


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Exercise 27-4 Leg Extensions (continued)

Exercise 27-5 Lateral Raises (Side Lifts)

4. I F lumbar extension is the primary movement, ask

Progression

675

the patient to pre-contract them, before leg

Not i n i t iated u n t i l patient capable of 4 to 5 sets of dor

extension.

sal raises ( 12 repetit ions). Start on 2 sets 5 each side ( may provide assistance/spot ) .

Advancement

Advance to 2 sets o f 1 0

Add ankle weigh t .

Maximum 2 sets of 10 w i t h upper board l owered as far as 45°.

Exercise 27-5 Lateral Raises (Side Lifts)

Advancement

Add free-wei g h t across t he c hest Correct Procedure

Side-lying on angle benc h , i l iac crest to upper edge of board. Lower board angled downward to first set t ing.

Alternatives

See chapters 5 and 26 for t h e s ide-bridge approach o f Stuart M c G i l l

U pside leg extended at knee, h i p at 0°. Downside leg nexed bringing ankle against u pside calf

Exercise 27-6 Gym Ball Squats

to secure legs under leg restraint. Start with upper board at just below 0° horizontal. Raise torso without twist unti l just above neu tral and lower. Ensure the pelvis remain perpendicular to the bench.

The Procedure

The pati e n t performs and holds co-cont raction. The patient stands with a gym ball between the small of the back and a wall. Then perform squats w i t h the weight against t he ball , ensuring that t he patient does not nex/ extend t he back. M a i n t a i n co-contractio n . -

1i 1

t

I

.:-..r_' • t

•

-

.

'.\'.

•

Advancement

Further advancement w i t h hand weights. Also, [Tee-standing squat, with hand weights or barbe l l . Notes

Wide-based squats are better for gluteal acti vity, narrow squats (wi t h a medicine bal l held between the knees) are better for act ivation of the V M O.

6 76

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Exercise 27-7 Abduction

Exercise 27-9 Pull-Downs

The Procedure

The Procedure

Maintain neutral s ideways standing posture and knee

W i de grip on t he bar w i t h correct , erect posture and co

extension t h roughout. Maintain gentle co-contract i on

conti-act ion

Ask t he patient to abduct leg to approximately 30° and

May be performed s i t ting or standing. Pre-contract

ensure it is "pure," w i thout h i p hike, rotation, or flexion.

lower scapulae stabi l i zers and depress the shoulder look [or ( the incorrect ) h i ke or trapezius. Pul l down to sternum in front of head.

Alternative

Si de-lying. Down-side leg flexed at the knee [or stability. Abduct the straight top leg. Advancement

Add ankle weig h t .

Exercise 27-8 Adduction The Procedure

Maintain neut ral s ideways standing posture and knee extension t h roughout. Maintain gentle co-contract ion Adduct leg to approx i mately 20° in [Tont of stance leg.

Alternative

Side-lying. Top side leg flexed at t he hip in front or the body. Adduct t he straight down-side leg advancing with ankle weigh ts as necessalY Advancement

Add ankle weight.


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677

Exercise 27-10 Neck Machine (continued)

Exercise 27-10 Neck Machine Correct procedure

Cervico-thoracic junction level with lever arm axis of rotation. Shoulders level and relaxed, hands on grips sit erect with t highs >900 (to decrease the use of the feet). Then activate lower scapula stabilizers and perform co contraction and deep neck nexion. Perfornl all movements within the pain-h"ee R O M Rest between sets 3 0 seconds t o 1 m inute.

Flexion

Pad level with l ower forehead, above the bridge of the nose. Lateral Flexion

Shoulders remain level throughout. Pad positioned just above ear. Progression

Progressed by incremental increases in resistance. A i m i n g gradually toward extensors 1 .7 : I nexors rat io. M a x i mal/comfortable levels should be achieved during

Extension

Arm level with external occ i p i tal protuberance. Extend without recruitment of trunk or l i m b muscles. DO NOT push through feet. Add deep neck Aexion/cervical cra nial nexion (as described in chapters 25 and 26)

(conti11ued)

assessment. Note

At the start of each R O M , a "warm-up" set or repet itions wi t h 0.5 kg of resistance should be performed.

6 78

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Exercise 27-11 Reverse Fly The Procedure

Patient prone on bench with suitable weigh t in hand

Exercise 27- 1 3 Gym Ball Phasic Dorsal Raises The Procedure

and extend arms with slight elbow nexion, shoulders at

Feet against wal l or secured, shou l der-w idth apart.

90° abduct i on. Co-con t raction.

Lying prone in straight line over bal l so navel is j ust

Shoulders must be depressed t h roughout and ensure

clear o r ball . Co-contl-action. H ands beside rorehead.

scapular ret raction is attained (main aim of exercise) and watch ror over active trapezius (shoulder elevation).

Lowering u n til hands as rar as poss ible and extending to j ust above neutral.

Alternatives

Wall angel or noor angel (often prererred by patients) Advancement

Perrorm over a gym ball in superman positio n .

Exercise 27-12 Supine Fly Correct Procedure

Supine on bench with suitable weigh t dumb bel l s . Arms abd ucted to 90° with sl ight elbow nexion . Bring weights up until they tou c h , and t hen lower. Maintain shoulder depression throughout . Alternatives

Push-ups, but watch ror winging and su perior migra tion or the shoulder (overact ive u p per trapezius). Bench press.

shown to h ave no s i gn i fi can t e ffec t on t h e cross sectional area o[ the m u l t i fid us in c hron i c l ow back pai n su ff erers. It is i n tended that a significant degree of com petence will develop in all aspects of the patient's exercises and i ndependence w i l l gradually develop. Although not i ndividually supervised at every visi t , the rehabi l i tation su pervisor will ensure that adequate progression is demonstrated through self-report, ob jective outcome questionnaires, functional tests, and demonstration of i ncreasing i ndependence.

Stage 3- Discharge and Independent Exercise The core exercises in t h i s section are descri bed i n Exercises 27- 1 3 , 27- 1 4 , and 27- 1 5 . Successful outcome of s tage 2 must clearly i nvolve functional and symptomatic i mprovement but, per haps more i mportan t ly, m us t h ave promoted self rel iance and an absence of fear-avoidance beh avior. Consequent ly, and somewha t parad oxically, success-

Notes

S i milar to aspects or t he supemlan track and promotes good stability because or labile surface.

ful cand idates wi l l remove t hemselves [Tom stage 2 i n t o their own environment, to con t i nue at home, with gym bal l phasic exercises or conventional gym exercise sessions. Patient Selection and Assessment

I n d eveloping and i n corporating rehabi l i tation in to c h i ropract i c care, it is esse n t i al to decide on a system


Exercise 27-14 Gym Ball Phasic - Leg Raises The Procedure

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679

Exercise 27-15 Gym Ball Phasic Lateral Raises

Prone over gym bal l resting [oreanns on floor. Tro

The Procedure

chanters to apex o[ bal l . Co-contract ion.

A d i fficult exercise and the patient should take care.

Raise legs as describes [or angle bench h i p extension,

S i de-lying on gym bal l w i t h u pside leg forward, and feet

and maintain a posterior pelvic t i l t .

secured at base o[ wal l . Main point o[ contact on gym ball

=

greater trochanter.

Cross arms across ches t . Raise and lower laterally. Notes

Promotes good stab i l i ty because o[ labile surface, but d ifficult to master. Requi res supervision in early stages because of trunk flexi on recru i t ment.

of iden t i fication for suitable cand ida tes. M ost im por tantl y, a screen of "red flags" is necessary to ru le out sinister pathol ogy and ensure the cond i t ion consid ered for isotonic t ra in ing is of a mechanical origi n l i kely to respond to reh abi l i tat ion (see Chapter 7 ) . I t i s c hiefly t he c hron i c i ty pred ictors that provide i nd i cators as to who i s most l i kely to benefi t f Tom a course of train ing (Chapter 9 ) .

Basic Premises for Referral T here are s i x bas i c prem ises d ic ta t i ng ref erral to stage 2 : 1 . The chief pred i ctor for chronic ongoing pain and d i sabil i ty appears to be c h ronicity i tself (54), and t h i s i s t h e m ost com mon reason for referral to the rehabi l i tation un i t . The maj ority of c l in ical trials of in tensive i sotonic t rain ing select patient population s with l ong-stand i ng pain d iagnosed as being of spinal origin (2 ,3,7,1 5 ,2 6 , 2 7 ,36, 37 ,45). 2. If chron k i ty describes ongoing ra ther than episod i c spin al pain, recurrence of sym ptoms f orms a second key ref erral i nd i cator. This is supported by previous work s howi ng h i gh recur ren ce rates at 1 year (84%) of low back pain in pati en ts w i t h confirmed segmen tal m u l ti fid us atrophy (21 ) .

Notes

Promotes good stabi l i ty because o[ labile surface.

3. The d i agnosis of d i scogenic pain forms another key referral cri terion . This is considered espe c ially i mportant For various reasons. Discal i nj uries h ave a relativel y poor prognosis and sur gical intervention is more common. Furthermore, because of the h i gh ly segmen tal nature of the i njury, the poten tial segmental i n h i b i t ion of the local stabil izing system and con sequent destabi-

680

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l i zation are considered to strongly predispose to fu ture recurrent pain and disabil i ty. I ntervention through isotonic tra i n i ng is considered appropri ate in the post-surgical patien t or af ter successful passive care (7,26,36 , 5 2 ) . 4.

T h e fourth standard criterion for referral is failure to respond . This encompasses a fai lure to i mprove at all wi th passive treatment and/or a p lateau of progress. At such a poin t, a further reh ab i l i tation assessment may well be appropriate.

S. Traumatic onset or spinal pain necessari l y consti tu tes a n i mportant reason for i sotonic train i ng, because muscle t issue i nj u ry and pain-related i n h i bit i on inevitably occur. Typical w i t h i n th is category are the whiplash-associated d isorders. 6.

Finally, given the poten tial for any acute pai n to become c hronic ( 1 0) , should a patient wish to begin a course of rehabi l i tation, i t is i nevi tably encouraged .

Ach ievin g Compliance

Compliance is a major issue in the successful out come of an intensive rehabi l i tation program. Fai lure to perform the program with to the standard required or a fa i lure to attend inevitably adversel y affects the outcome ( 1 4, 1 8 ,46). To reduce non-compliance, several issues need to be considered: 1.

The cost and t i m e com m i tment are d iscussed w i t h the pa tient before referral to the program . A start date i s agreed when t h e patient wi l l be able to at tend consisten tly over a ( m i n i mu m ) 1 0-week period. Fail ure t o i d e n t i fy t h i s w i l l l ead to ( i ) non-acceptance i n t o the program , ( i i ) a program wi t h reduced supervision, or ( i i i ) a home-based program but only u ndertaken i f the supervisi on-compl iance relationship i s d i scussed .

2. The nature of the tra i n i ng program is also dis cu ssed i n deta i l . The patien t s hould know what to expec t once trai n i ng begins. 3. Also at this stage, the l i kely benefits to the patient are discussed. Because t h e l iterature and our own experiences support i mprovement i n pain i n tensi ty, frequency of episodes, and duration of epi sodes i n the average patient u ndergo i ng such programs, these are identified as t h e l i kely changes. However, because no patient i s truly "average," it is necessary to explain th at the spe ci fic benefi ts to the i ndivi dual are unpredi ctable. They are also counse lled t hat i mprovement may not be seen u n t i l the sixth week (38 ).

4.

Also, th e "relative neglect o f pa i n" M UST be dis cussed with the patient.

S. Appropriate pat ient selection is paramount be cause despi te the i nsistence of many i nsurance companies, rehab i l i tat ion is not for everyone! Com p liance is only mai ntained IF the i ndividual i s motivated or open to such mot ivat ion. The staff may encourage this, but largely this is up to the i n d ividual. 6.

F i nally, selection of the appropriate rehabil i tation supervisor i s essential and should not be underes t imated. Positive reinforcement, encouragement, and an understanding nature are probably the most i m portant attributes that the supervisor can have when dealing with the de-conditioned pain sufferer. Good i n itial intentions and motivations are eas i ly eroded if early attempts at exercise exacerbate the problem. The ski l l of the super visor is to encourage, enthuse, and motivate the patient beyond i n i tial early discomfort toward i ndividual goals.

Consequently, although the young patients with first time, post-acute l ow back pain are excellent candi dates in whom to promote rehabi l i tation and prevent c h ronicity, they are u n l i kely to comm i t to an ex tended supervised progra m . Conversely, the i ndivid ual wh o has su ffered recurrent bou ts of pai n and has "been everywhere" with l i m ited success and "wants to do somet h i ng for h i m self" may be ideal and, more over, motivated .

Exclusion Cri teria

Most o f the excl usion cri teria for isotoni c tra i n i ng are th ose t h a t are excl u s i on fl-om reh abi l i tation in i ts e l f. These range fTom undetected or uncontrolled hypertension, the presence or pathology, etc., and are largely beyond the scope of this chapter. However, there are c l in ical considerations that may lead to the patient being excluded f rom rehabilitation. I t may be desirable for the rehabil i tation supervisor to conduct cardiovascular assessment to ensure heart rate and blood pressure responses to exercise are within nor mal l i m i ts and to use a sui tabl e questionnaire. Alth ough i t i s rare to exclude an individual who is motivated to attend rehabil i tation from isotonic train i ng protocols, the authors h ave modi fied the original "disregard of pain" concept, because a number of peo pIe did not cope wel l with this approach . Most of these i ndividuals demonstrated signi ficant fear-avoidance behavior (demonstrated through such measures as the B ournemouth Questionnaire; chapter 8) and required a l ess vigorous approach. Consequently, although patients are encouraged to set their own


goals and are "pushed" to achieve these, a n u mber are removed fl-om isotonic trai n i ng and transferred to an alternative program i n i t ially, progressi n g to i sotonics at a l ater s tage. Furthermore, in the case of neck pai n, the authors have noted that patien ts need to have a relatively full and painless range of motion and need to be in a peliod of rem ission to progress wel l . Largely, the more acute neck pai n su fferer will be put on active range of movement exerc ises, cervical spine sensorimotor training, and eye-neck coordination protocols, rather than isotonic training machines.

Assessment Criteria As with clinical assessment, t here are few pathogno monic tests in rehabil i tation assessment, so the clin ician must use j udgement i n the i nterpretation of the i n formation that can be gleaned from t h e gamu t o f tests at t h e i r disposal. T h e i n i t ial tests aim to iden t i fy general muscle imbalance: •

•

Posture: Postural analysis t hrough the methods described by Janda and by Liebenson is applied as a general screen . Postural syndromes (e.g. , upper crossed syndrome, lower crossed, etc.) are identified along with more local abnormalities (e.g., lumbar lordosis length, sacral angle etc . ) (chapter 1 0). Movement Patterns: These allow the exam i ner to more specifi cally assess the combi ned function of global m usculature as i t pertains to joint stabi lization during movement. Evidence of muscle over activity or shorte n i ng can be correlated with findi ngs on specific m uscle

681

length analysis and posture. The key patterns assessed are the tru n k flexion, hip extension and hip abduction movement patterns for the low back and tru nk loweri ng, neck flexion , and arm abduction for the u pper body (chapter 1 0) . Further associated motion assessmen t , e.g. , the squat or lunge test m a y also be appropriate. (Chapter 34 ) •

•

Assessment

Ind ividual assessment and prescription that are tai lored to individual's needs, rather than general l ow back or neck programs, have been shown to be m ore effective than programs ( 1 3). Assessmen t procedures i n tegrating various aspects of musc l e function for spinal disorders have been devised. Tests of strength and endurance, which assist the prescription of, and emphasis on, isotonic exercise, are supported by tests of local muscle function, muscle tone, and length imbalance and sensorimotor fu nction. In com pleting t hese exami nation routines, t he ex ami ner identifies defici ts i n the various parameters of muscle fu nction as it pertains to spinal stabilization, so that rather than merely "blanket" prescription of isotonic training an i ntegrated package of exercise procedures tailored to the individual's requirements may be devised.

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M uscle Length : Assess muscle lengths of t h e postural groups, which are prone to hyper tonic ity and may have a role in perpetuat ing or predisposing to recurrence of spinal-related condi tions. (Table 2 7 . 1 ) Local Stabil ization Tests: M uscle con trol o f the l ocal s tabi l i zers is tested through pressure biofeedback of transversus abdom i nus contrac tion and palpation tests o f multifidus for the low back and through the measurement of cervico-cranial flexion endurance!coordination in the neck. These procedures are described i n c hapter 2 5 . Sensori motor Fu nction: Sensori motor fu nction as it pertains to l ow back stabi l i zation is assessed through the one-leg stand test, Hautant's test, U n terberger's test, and Fukada-U n terberger's test . Additionally, head reposit ion i ng accuracy may be sought and retrained to promote the cervico-occular reflexes (47). These tests may be selected based on h i stori cal indicators.

A l l t h e i n formation provided through t hese exami nation procedures provides prescriptive indica tors for the exercises, which may be used to complement the isoton ic tra i n i ng. More specific i n formation pertai ning to isotonic training may be provided through t he fol lowing quan tifiable local stabilization, isometric, and isotonic tests: 1.

Quantifiable abdom i nal muscle tests: such as t he prone abdom i nal drawi n g i n test and various tru n k flexor tests as descri bed in c hapter 1 1 are useful for establishing basel i nes fTom w h i c h to j udge progress with abd o m i n a l exercise rou t i nes.

2 . I sometric e n durance o f the erec tor spinae: iden t i 6ed by B ierri ng-Soerenson as having a strong correlation w i t h the development o f first t i m e l ow b a c k pain and w i t h recurrence ( 7 ) , t h i s test is valuable prescrip tively and as an outcome m easure. Subseque n t trials have further soug h t to clarify t h e rel i abi l i ty and spec i 6city o f t h i s t e s t (33,34 ,44), and i t has b e e n cri ticized a s being t o o dependent o n motivational factors, but it remai ns one of t h e best-known methods

682

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Table 27. 1

PosLural M uscles o[ the Low Back and Neck

Low-Back Groups

Neck Groups

Lu mbar extensors G l u teals Abdom i nals Abductors Adductors Quad riceps H amstri ngs Latissimus dorsi Multi ndus & transverse abdo m i nus

Neck flexors Neck extensors Neck l ateral flexors Sub-occi pital m uscles Lower trapezius Pectorals Serratus anterior

[or assessing l u m ba r extensor endurance. One possible l i m i Lation of t h i s test is that it m ea sures s lalic isometric end urance. Because t h e tra i n i n g is i s o l o n i c , t he authors feel a m o re dynamic lesL may be more appropriate as an ouLcome measu re ( 9 ) . 3. Dorsal raises: T h e l u mbar extensors c a n be tested isotonically, a tesL w h i c h is preferred by t h e a u t hors. I sotonic test i ng of t h e erec Lor spi nae i nvolves the use o f an angle bench and req u i res L h e patient to perform t h e i r m ax i m u m n u mber o f d orsal rai ses. W h e n to stop i s t h e decision o f t h e p a L i e n t , b u t t h e pati e n t i s guided to conti nue u n t i l u nable to perform another repet i t ion w i L h ouL faL i gue or pain to 5 ° exten sion (see art in Exercise 2 7 - 2 ) . The test i s per formed t h rough angles of flexion rather t h an [Tom n e u L ral Lo extension because o f length/ten sion re l a L i o n s h i p issues and because t h i s is more represen tative of typical acts of dai ly l i v i n g (ADLs) and d i rect l y comparabl e to t he pro gram bei ng u ndertaken. This test has p reviously been described i n t h e l i terature (34,43 ) . To fur ther assess rel iabi l i ty and h e l p establish norma L ive data, a further study o f n ormal subjects is curre n L l y i n press (9). Curre n t ly , our observa tions are L h a t in t h e c h ro n ic low back pa i n popu l a t i o n , a typical range o f values is 1 0 to 2 5 repeti t ions. 4.

I so me t ric tesL i ng o f maximum vol u ntary con traction ( M . V . C . ) i n the cervical spine: T h is may be assessed by a digi tal strain gauge attached to the "neck mac h i ne . " The rel iabi l i ty o f t h i s device and n ormative data h ave been publ i sh ed ( 2 8 ) . A n alternative method is t hrough t h e use of a sphygmomanometer, i n which forces of t h e n ec k are measured when a patient pushes i n to t he blood pressure cu ff, w h i c h is pre-infl ated to 20 mmHg (53).

Deep n eck flexors

s. l ul l 's cervico-cranial flexion test: lull has described a simple screen i ng tesL [or deep neck flexor weak ness ( 5 3 ) . This is a progressive tesL of cervi co cranial flexion motion, coordination , and endurance using a pressure biofeedback device (see C hapter 2 5 ) .

Prescription DeLailed assessments al low the identi ncation of de fici ts in the musculoskeleLal sLabi l izing sysLems, allow i ng a fai rly "lesi on-specinc" approach to prescribing corrective i nterventions/exercises. When prescribing an exercise regime, the pri mary i ntervention is t he relaxation and if necessary sLretch ing of overactive or shortened muscle grou ps, fol l owed by t he promotion of local stabi lization (stage 1 ) . This advances t hrough the exercise program (stage 2 ) t o sel f-reliance (stage 3 ) . T h e prescribed program needs t o be flexi ble enough to allow a l l defici ts to be trained within a single re h abi l i tation session (usual ly 45 to 60 mi nutes) i f necessary, o r al ternatively t o focus o n a part icular weakness. Wi t h i n a largely standardized framework, there is room to de-emphasise or even omit exercise tracks in which the patient has demonstrated compe tence to focus on areas of weakness. For example, the patient may demonstrate l i ttle or no sensorimotor or m uscle l ength problems but may have obviously inadequate global and l ocal muscle aCL ivity. Al terna tively, some patients (such as ath letes) may demon strate excellent flexi b i l i lY, strengt h , endurance, and balance but fai l a test of co-contracLion and demon s trate segmental mu ltifidus atrophy, i ndicating a need to concentrate almost entirely on local stabi lization training. Local muscle dencit is trai ned with continued lo cal s tabi l i ty t ra i n i n g , and the global defi c i t i s tar geted t h rough the prescri ption of isotonic exerc ises,


as identi ned in exercises 27-2 to 27- 1 2 . M ost patients will perform a l l the exerc ises, but the muscle groups trained hardest will be identi ned and corrected accord ing to Table 2 7 . 2 . T h e emphasis placed on each depends on t h e per formance duri ng the assessment, with speci nc regard for the lumbar nexors and extensors. The emphasis must depend on the correction o[ normal s trength ratios. The co-co n t rac t i o n track for spi n a l s tabi l i za tion involves a h ig h degree o f spec i fi c i ty, and meth ods such as pressure biofeedback and rea l- t i m e u l t rasonography have been used b y t h e i r deve l op ers ( 1 9 , 2 0 , 2 3-2 5 ) to ensure the correct action at every stage o f advance m e n t . O nce t h e p a t i e n t is on t he isotonic resi s t ance equipmen t , t h ere i s n o guaran tee t hat co-con trac t io n i s m ai n ta i n ed ; we must rely on the patient's ki naesthetic awareness of t he correct contrac t i o n . As Rich ardson states: "Al the presen l lime l here are no melhods for checking if appropriale con l rol of segmenlal motion is occurring during funclional lasks."

Table 27.2

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683

There is also a case for i ncorpora t i n g t h e equiva l e n t cervical method o f local stabi l i zer recru i t m e n t , i . e . , l ower scapul ar stabi l i zer cont raction a n d cervic ocranial flexion, to i sotonic neck exercises. But t h i s i s complex a n d requires a h igh level of competency to ensure the correct procedure. Consideri ng the i ntegration of sensorimotor train i n g with isotonic exercise, t h e l i terature does not appear to offer any specific gu idelines. Therefore, it i s logical to address t hese i ssues i n para l l e l . The patient m ay i n i t iate sensori m otor trai ning (such as balance board tracks and o ne-leg stand exercises) at t he same time as i so tonic exercise. I n the later stages of the l ow back program, the aspects of sensorim otor, co-contraction, and endur ance train i ng become in tegrated when exercises such as dorsal raises, leg raises, and lateral raises are trans ferred from the angle bench to t h e gym bal l , i .e . , [Tom a stable to a labile surface. This l eads to stage 3 , inde pendence and discharge. Holding co-contract i o n w h i l e perform i ng dorsal raises on a labile surface such as the bal l is clearly an advanced exercise, but it cou l d be argued t h i s pro-

Correlation of Functional Test, Isotonic Exercise, and M uscle Groups Trai ned

Test

Example o f an Isotonic Procedure

Muscle Groups

Isometric endurance test Dorsal raise test H i p extension movement pattern

Dorsal raises

Lumbar extensors Hamstrings Gluteals

Hip extension movement pattern

Wide-stance bench squats H i p extensions

Gluteals

Trunk nexion movement pattern Quan ti nable abdomi nal muscle test

Curl-downs, sit-ups, crunc hes, gym ball curl-ups, fi tter

Abdom i nal muscles

H ip abduction movement pattern

Side raises or side-lying abductions/ adductions

QL, h i p abductors/adductors

Neck nexion movement pattern o[ landa lull's cervico-cranial flexion test Neck nexors M . V . C .

Resisted flexion on neck mac h i ne ( note ratio)

Cervical flexors

Neck extensors M .V.C.

Resisted extension on neck m achine ( note ratio)

Cervical extensors

Neck lateral flexors M .V.C.

Resisted flexion on neck machine (equal ratios)

Cervical lateral flexors

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vides m u l l i p l e t herapeutic benefits. For that reason alone, it cou ld be argued that the spinal stabi l i zation exercises (c hapter 26) are superior to t he gym-based isotonic approac h .

Concurrent Passive C are

Given that the benefi ts o f t h e program w i l l not typi c a l l y become appare n t u n t i l several weeks after commencem e n t , it is i nevi table t hat most patients will experience some o ngoing, or even i n c reased, d i sc o m fort in the early stages of tra i n i ng. Manniche (38,39) noted that in a Low back pain pop ulation, im provements were not fel t u n t i l 5 to 7 weeks of rehabil i tation. Clearly, concurrent passive care is appropriate [or most patients u n t i l t heir symptoms improve and they achieve greater i n dependence. A l t h ough a "relat ive disregard" of pai n is advo cated , we have become m ore pragmatic as the pro gram has devel o ped and h ave n o t i n s tructed people to c o n t i n u e to work u n t il our goal s are m e t , rather u n t i l t h e i r goals are m e t . Addi tional l y, the B ierring Sorensen test has now bee n , l argely, rem oved [Tom the progra m because we fou n d t h a t a n u m ber o f people had a re trograde s t e p before rehab i li ta t i o n caused b y t h e i r sustai ned h o l d i n g of t h i s pos i t i o n . Also, t h i s t e s t , i n t h e sym ptomatic patie n t , i s n o longer one o f e n d u rance b u t ra ther a t e s t o f pai n t o lerance.

Post- Isotonic Program Reassessment

Reassessment may be fomlal (as in the i n itial referral to the program) or i n formal ( taking place in the gym duri ng an exercise session) and, largely, toward the end of the program the patients are i n three categories: 1.

Discharge and m ove to i ndependence. Many peopl e gradual ly go t h rough an i n formal reassessment and leave t he rehabi l i tation center having m ade significant gains and move o n to a gym or i ndependent home-based program .

2 . Fai lure t o respond. The l i terature suggests that the average time for a rehabil itation program is between 8 and 1 2 weeks, with response expected within 5 to 7 weeks ( 5 ) . Clearly, not everyone is "average" and a fai l u re to respond by 6 to 8 weeks is likely to require a formal reassessment. The palients' goals and expectations are revisi ted and a re-evaluation of their performance u ndertaken. In our experience, and if t hey are w i l l i ng to con tinue beyond such a poin t , most people respond

IF they can master co-contraction and exhibit good "form" in their exercises. 3. A signi ficant proportion of people are not "exer cise-types" and recogn ize their own shortcomings. They real i ze that t hey will not con ti nue alone at home (with phase 3 ) and prefer to continue at the rehabil itation cen ter. Their own program will be negotiated individually such that it will give t hem weekJy (or every 2 weeks) contact with the reha bil itation staff, allowing periodic supervision and advancemen t . They will also conti nue at home.

C ases

Case 1 - Mrs. R. (Ratio Correction) M rs. R . , a 63-year-old woman, h ad been suffering from periodic, recurren t bouts of low back pain since her first acute episode at the age of 28. In recent years the bouts had become more fTequent and more per sistent and, a L though she had previously enjoyed long periods of relief from passive treatmen t , she was now having contin uous trouble. Mrs. R. had been a com peti tive swim mer si nce her younger years and contin ued to swim (breast stroke) some significant distance "at least three t imes per week." M rs. R. stood with a lower-crossed posture. Her hip extension movement pattern demonstrated early activi ty of t he b i lateral erector spinae. The leg abduc tion pattern showed tightness of the i l i opsoas and her tru n k flexion pattern was normal, alt hough she was not capable of perform ing si t-ups without l i fting her feet. M rs. R.'s B iering-Sorenson test (erector spi nae endurance) exceeded 240 seconds. Her history of swim m i ng is typical of an individ ual who does not cross-train sufficiently. Her erector spi nae endurance is exceptional for her age ( and typ ical of a dedicated swi m mer) bu t it is sign i ficantly out o f balance with the strength of the abdom inal muscles. Clearly, trai n i ng her low back musculature was not i mportant. Her program i nvolved the redressi ng of this bal ance and, after 8 weeks, she was sign i fican tly better. Abdom i nal work is now i ncorporated into her train i ng regi m e .

Case 2 - M r. J. (The 10-Week Program Is Only "Average") M r . J . , a 43-year-old man, was referred to the rehabil i tation center by his medical practi tioner. H e had been off work for the past 30 months after a fal l from his horse, which caused "intractable weakness" in his low back. The pain was constant at 5 on a scale of 1 0, and "any exercise" aggravated t he pain to 8 to 9 on a scale


of 1 0. He had been s igned off work as permanently disabled but was keen to attempt anythi ng t hat may help. He had not ridden a horse si nce the acci dent. Mr. 1. took 4 weeks to master the co-contraction exercise. At that stage he still could not be assessed [or erector spinae endurance because it was fel t that this wou l d aggravate his pai n . H is movement pat terns were normal i n terms of movement sequences and pat terning, although generally "weak." Mr. 1 . was an extreme example o f the decon d i tioned pat i e n t . After 20 weeks i n t h e reh ab i l i tation gym, after beg i n n i ng with co-contraction and bui ld ing up through gym bal l phasic exercises and the use of t he "fitter" for abdominal work, he became ful ly independent. He was reduced to weekly and then two weekly visits and d ischarged approxi mately 6 months after his first exercise assessment. He converted part of h i s house i n to a dedicated l ow-technical gym and conti nues his exercises. Mr. 1 . has begun h orse riding aga i n and works as a counsellor in drug and alcohol abuse.

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What al-e the principles underp i n n i ng i sotoni c tra i ning i n rehab i J i tation ?

•

Outline t h e key elements i n the design o f a n i sotonic tra i n i ng which are l i kely to i mprove t h e program's effectiveness.

•

What is core stability and why is it i m portant?

•

Define normal strength and endurance measure ments and t h e rat i os of agonist-antagonist rel at i ons h ips?

• •

Devise an assessment procedure. For any given spinal muscle group insufficiency, w h i c h isotonic exercises m ight be used in i ts correct i o n ?

• ACKN OWLED G EMENTS

Case 3- Mr. B. (the Importance of Local Stabilization) M r. B. is a 3 2 -year-old t ri-athlete w h o i s , needless to say, very [i t . He trains daily and conducts a sen sible cross-training regime, i nvol ving cyc l i ng, run n i ng, swi mming, and gym work . However, despi t e this activi ty he experiences back pai n with ru n n i ng. He has experienced l i ttle rel ie f from various pract i tioners o[ passive care, despite all ow i ng t h e m a "rea sonable" wi ndow of time to treat h i m . Mr. B.'s strength tests were norm a l , w i t h the major deficit iden t i fied in h is assessmen t being t h e i nabi l i ty to hold a n d m a i n t a i n co-contraction, a n d i t was this that was trai ned , largely outside o f t h e reha b i l i tation gym environment-som e t h i ng that can be achieved by the dedicated sportsman. M astering t h i s simple exercise afforded h i m a significant decrease in the severi ty o[ the pai n , w h i c h now only comes mildly and towards the end of an eve n t .

• CONCLUS I O N Trai n i ng t h e spi nal stabi l i zation system requi res a combination o[ fine motor control and isotonic exer cises. One of the most i m portan t reasons to i nclude isotonic programs is that many patients are h ighly motivated to work out i n gyms, thus maki ng greater compl iance with such a program feasible. Natura l ly, by combin i ng the princi ples of local stabil i zation motor control i n to global stab i l i zation exercises, greater safety and effectiveness can be anticipated.

The authors t h a n k Zoe Scott for her contri b u t i o n to t h i s c hapter and, moreover, for her i nvaluable con tribution to t h e Rehab i l i t a t i o n Cen t re at A ECC.

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3 1 . J uker D , M c G i l l S M , Kropf P , Steffen T. Quanti tative i ntramuscular myoelectric act ivity of l u m bar por tions of psoas and t he abdomi nal wall during a wide variety o[ tasks. Med Sc i Sports Exercise 1 998;30:30 1 -3 1 0.

1 5 . Frost H , K1aber Moffett J A , Moser JS, Fairbank JCT. Ra ndomised control led trial for evaluation o f fitness program [or patients with chroni c low back pai n . B M J 1 995 ; 3 1 0: 1 5 1 - 1 54 . 1 6. Graves J E, Pollock M , Foster 0 , Legget S H , Car'pen ter D M , Vuoso R, Jones A. The E [[ect o f tra i n i ng fre quency and spec i ficity on isometric l u m bar extension strength. Spine 1 990; 1 5 : 504-509. 1 7 . Hard i ng YR, Si mmonds R, Watson P. Physical therapy [or c h ro n i c pain. Pain Cl i n U pdates. 1 998; I ASP2(3): ] -4 . 1 8. H arkapaa K , Jarvikoski A , M el l i n G , H u rri H . Con t rolled study o n the outcome o [ i npatient and out patient t reatment o f low back pai n . Scand J Rehabi l Med 1 989;2 1 :8 1 -89. 1 9. H ides JA and Richardson CA. M u l ti fidus m uscle recovery is not automatic after resol u t ion of acu t e , first episode low back pai n . Spine 1 996 ;2 1 : 2763-2769. 20. H ides JA and Stokes. Evidence o[ l u m bar m u l tifidus was t i ng i ps i lateral to sym ptoms in patients w i th acu te/su b-acute low back pai n . Spine J 994 ; J 9: 1 65 - 1 72. 2 1 . H i des JA, Richardson CA, J u l l GA. M u l tifidus muscle recovery is not automatic after resolu t ion o f acute, first-episode low back pai n . Spine. 1 996;2 1 :2763-2769. 22. H ighland TR, D reisi nger TE, Vie LL, Russe l l GS. Changes i n isometric strength and range of motion of the isolated cervical spine after e ight weeks o f c l i n ical rehabi l itation. Spine. 1 992; 1 7( 6 Suppl ) : S77-S82. 23. H odges P, Richardson CA. Inefficient stab i l i zation o f t h e l u m bal- spine associ a ted w i t h l o w back pain. Spine 1 996; 2 1 :2640-2650. 24. Hodges P. Is there a rol e for transversus abdom i nus in l u m bo-pelvic stab i l i ty. Manual Ther 1 999;4: 74-86 . 25. H odges P. Transverus abdo m i n u s : t h e forgoLLen m us cle. Proceedi ngs of the 3rd i n terd isc i p l i nary world

32. Kumar S, Dufrense R M , VanSchor T. Human tru n k strength profile i n nexion a n d extension. Spine 1 995;20: 1 60- 1 68 . 33. Latimer, J , Maher, C, Refschauge, K, Colaco, T . The rel i ab i l i ty and val i di ty of the Bieri ng-Soerensen test in asymptomatic subjects and subjects report i ng current or non-specific low back pa i n . Spine 1 999;24:2085-2090. 34. LaLLika P , Battie M C , Vi derman T, G i bbons LE. Cor relations o[ isoki netic and psychophysical back l i ft and static back extensor endurance tests in men. Clin B i omechanics J 995 ; I 0:325-330. 35. Luoto S, H e l i ovara M , H urri H, Aiaranta H Static back endurance and the risk of low back pa i n . C l i n B i omechanics 1 995 ; I 0:323-324. 36 . M a n n i che C, Jordan A. Editorial . Spine 1 995;20: 1 22 1 - 1 222. 37. Manniche, C Lundberg E , Christensen I , Bentzen L , Hesselsoe G . Intensive dynamic exercises for chronic low back pain: A c l i nical trial . Pain 1 99 1 ;47:53-63. 38. M an n iche C. I ntensive dynamic back exercises with or without hyperextension in chronic back pain after surgery for l u mbar d i sc protrusion: A c l i n ical trial . Spine 1 993; 1 8 : 560-567. 39. M a n n iche C . Low back pain and exercise. Ugeskr Laeger J 993; J 5 5 : 1 42- 1 44. 40. McAuley E , Courneya KS, Rudolph D L , Lox CL. Enhancing exercise adherence i n middle-aged males and females. J Prev M ed 1 994;23:498-506. 4 1 . McGi l l S M . Low back stab i l i ty: From formal descrip t ion to issues for performance and rehabil itation. Exercise Sports Sci Rev 200 J ;29:26-3 1 . 42. McG i l l S. Low back d isorders: evidence-based pre ven t i o n and rehab i l itation. H u man K inetics, 2002. 43. Meyer TG , Gatchel RJ, M ayer H , K i s h i no N D , Keeley J, M ooney V. A prospective 2 year study of funct ional restoration in i ndustrial low back i nj u ry: an objective assessment procedure. JAMA 1 987;25 8 : 1 763- 1 767.


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44. Ng J K, Richardson CA. Rel iabi l i ty o f electromyo graph i c pO\.ver- spectral analysis of back muscle endu rance i n heal t hy subjects. Arch Phys Med Rehabil 1 996;77:259-264.

49. R issanen A, AJar-anta H, Sainio P, Harkonen. 1so kinetic and Non-dyna m i c tests in low back pain patien ts related to pain d i sabi l i ty i ndex. Spine 1 994; 1 9: 1 963- 1 967.

45. Pollock M L, Leggel t S H , Graves l E, Jones A, F u lton M , C i ru l l i l . E ffect of resi stance tra i n i ng .on l u m bar extensor strengt h . Am 1 Sports Med 1 989; 1 7: 232-238 .

50. Rissanen A , H e l iovaar-a M, A laranta H, Tai mela S, M a l k i a E , Knekt P , Reunanen A, Aromaa A. Does good trunk extensor performance protect against back-related work d isab i l i ty? J Rehabil Med 2002;34:62-66.

46. Rei l ly K, Lovejoy B , W i l l iams R. Roth H. D i fferences between a sLlpenrised and i ndependent streng t h and cond it ion i ng program w i t h chronic low back syn dromes. J Occup Med J 989;3 1 : 547-550. 47. Revel M, M i nguet M , Gergoy P, Vai llant l, Thomas E, Silman Al. Changes i n cervicocephal i c k inaesthesia after a proprioceptive r-ehabi l i tation program i n patients w i t h neck pain: a randomised controlled trial . Arch Phys Med Rehab 1 994; 7 5 :895-899. 48. Richardson CA, Snijders CJ , H ides l A , Damen L, Pas MS, Storm J. The relation between the transversus abdominis muscles, sacroil i ac joint mechanics, and low back pain. Spine 2002;27 : 399-405.

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5 1 . Saal l A , Saal l S. Non-operative management of her niated cervical i ntervertebral disc w i t h radiculo pathy. Spine 1 996;2 1 : 1 877- 1 883. 52. Sch i fferdecker-Hoch F, Denner A. Mobil i ty, strength and endurance parameters of the paraspi nal muscu lature. Age and gender speci fic refer-ence data. Manuelle Medizin 1 999;37: 30-33. 53. Vernon H. Muscle strength test i ng of t h e neck w i t h a manual mod i fied sphygmomanometer dynamo meter. Eur 1 Ch ir 1 994;44:4 1 -49. 54. Waddell G. Low Back P a i n : A twentieth Century Enigma. Spi ne 1 996; 2 1 : 2820-2825 .

Weight Training for Back Stability

Chris Norris

When Is Weight-Training Appropriate? Concepts of Resistance Training Overload Fitness Components

Learning Objectives

After reading this chapter, you should be able to understand: •

Weight-Training Methods

Safety Factors in the Weight Gym

•

Control the Weights Appropriate Clothing

•

Equipment Adjustment Personal Limits

•

Listen to the Body

Postural Alignment in Weight-Training Practice Rehearsing Correct Alignment Patterns Machine Exercises

Free-Weight Exercises Special Concerns Regarding Free-Weights Basic Free-Weight Exercises

Free-Weight Exercises for Explosive Power Power Training Using Plyometrics Before You Start Plyometric Exercises

688

•

How to progress patients from Ooor to isotonic weight machine regimes H ow to incorporate stabil i ty pri nci ples i n to health club exercises H ow to vary i n tensi ty, sets, and repetit ions to achieve strength - trai n i ng goals The basic weight machi nes that can be used to train endurance and strength i n the torso mus cles and how to prescribe their use The basic free-weight and medicine ball exer cises for developing strength and power in the trunk and lower quarter

Chapter Twenty-Eight: Weight Training for Back Stability

We have seen in Chapters 2 and 25 that muscles may be categorized into local and global types. Enhan c i ng endurance of the local muscle system and reducing the domi nance of the global system has been pro posed as a h.ll1 c tional met hod of low back rehabilita tion ( 1 2,9). However, reducing a patient's reliance on the global system to supply muscle stabi l i ty to t h e low back h a s l e d to a tendency among some clini cians to forget the global system entirely and seek to enhance the performance of the local muscle system in isolation. However, the use of weight-train i ng to en hance back stability has been shown to be an effec tive clinical tool ( 1 3 ) and to forbid i ts use is to with hold a poten tially valuable method of treatment in low back pain (see C hapter 27). Interaction between local and global muscles (2) occurs by the local muscles con t roll ing stability and subt le local movements o f the i ndividual l u m bar egments, whereas the global m uscles balance exter nal forces that woul d tend to move t h e spine away from its neutral posi tion. In addi tion, global muscles act to st2bilize in t imes o f extreme need , and both sporting actions and manual hand l i ng represen t such occurre nces. Weigh t-training for back s tabil i ty may be used either as a fi nal progression to a general stability pro gram or for technique i nstruction of individuals undergoing stability training who cUITently train in a gym as part of a general fi tness regime. One of the essential questions for the cli nician is when to move a patient fTom noor exercise for stabi l i ty ( free exercises and gym balls) to weight-based exercise ( mach ines and fTee-weigh ts).

When Is Weight-Training Appropriate?

Before begin ning a weight-training program , a patient must have good core stabili ty. Tech n iques to measure this and hmdamental exercises to enhance core s ta bility have been described in Chapters 1 1 , 2 5 , 26, and

Table 28.1 • • • • • • • •

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689

34. Table 28. 1 rei terates the esse n t i a l req uirements before a patie n t should be allowed to begin a weigh t train i ng program. Back stabi l i ty tra i n i n g h as been descri bed as par alleling t h e t h ree s tages of motor learni ng ( 9 , 1 0 , 1 5 ) . I solated muscle work ( i n t h i s case o f t h e deep mus cle corset ) represents the firs t s tage, and it is esse n tial t h a t t his h as been com pleted be fore weig ht trai n i n g commences. In t h e second stage t h e essen t ia l feature is t hat the subjects are n ow able to rec ognize and correc t t h e i r own m i st akes in t h ese si m p l e actions. C l i n i ca l l y t h is means t h a t subjects know when t h ey h ave m oved away from the n eutral lumbar posit i o n and are able to m ove back at wil l . Once t h is i s ach i eved , complex movements are sub d ivided in to t heir [L1n damental componen ts and t hese are learned while main tai ning a neu tral spi nal posi t ion. L i m b m ovements are often used on a sta ble base duri ng this stage, and basic weigh t-tra i n i n g movements wi t h machi nes may also b e used. A grea ter variety o f movemen ts are requ i red with fTee-weight exercises, and so t h ese are used as a progression on the mac h i n e exercises. As t h e subj ects move into the t hi rd s tage o f motor learni ng, the essent ial feature is that they are now able to control the position of t heir lumbar region and stabil i ze with li ttle al len tion. This represents automatic action and faster explosive exercises may now be used.

Concepts of Resistance Training Overload

For m uscle tissue to strengthen, i t must adapt to a resistance t hat overloads i t . Overloading occurs only when m uscle con tracts at a level greater than that of everyday living. For example, flexing and extending the elbow occurs i n everyday activities, so to perform t h i s movement alone will not overload t h e arm nex ors. Overload will only occur when t he fTeque ncy, intensity, duration, and type o[ m ovement is greater

Before Begin ning a Weight-Tra i n i ng Program the Subject Should Be Able to:

Iden t i fy neutral lumbar position I den t i fy and main tai n neu tral posi tion while perform i ng limb movements Avoid muscle substitution strategies while mai n taini ng neutral position Breat h normally (avoid breat h holding) while main tain i ng neutral posi tion Maintain neu tral l umbar posi tion for 1 0 repetitions of a 10-second limb movem e n t . Perform al len tion demanding movements w h i l e mai n taini ng neutral posi tion Perform the hip hinge action ( page 695) correct l y and for 5 repeti t ions Have a basic knowledge of postural alignment and manual handling techn i ques associated with gym apparatus.

690

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than that which is fam i l i ar to the body. For basic sta bi lity work, m uscle endurance is required, and exer ci ses must rehearse correct m ovement patterns. Exercises at t h i s stage have a fairly long duration ( 1 0 to 30 seconds) for each repetition, w i t h the a i m of recrui ti ng type I fibers. T h e type of movement cho sen must reflect correct l u m bo-pelvic alignment. Moveme n ts for the m a i n should be performed with the lumbar spine i n i ts neu tral position, w i t h the li mbs movi ng on the trun k as a fairly i mmobile base. The i n tensity of the actions is low and to familiarize the patient with the movement the frequency is h igh . For example, actions such as abdominal hollow i ng and m u l t i fidus recmi tment (Chapter 2 5 ) m ay be per formed throughout the day to bu ild the patients awareness of the action . Through h igh repetition of movement, the action becomes so fam i l iar t hat i t will eventua1ly become more automatic. When the patient is able to perform t hese actions automatically (wi th out sel f-pal pation, for example) he/she may use m ore complex weigh t-train i ng exercises using free-weights. As t he complexi ty of an exercise i ncreases, the fre quency should reduce so the patient does not degrade his/her perform ance at a particu lar task. To i ncrease strengt h , heavier resistances and fewer repet i t ions ( 8 to 10) of an exercise are used. In so doing, l arger-di ameter muscle fibers are recmi ted ( 1 4 ) and a greater percentage of type II ( fast-twitch) fibers. To maintain m uscle balance, it is essen tial that core stability exercises be main tained. I f good core sta bi lity is achieved , type I fiber activi ty should balance type I I activity. Should a patient move on to weight train ing activit ies and simply forget core s tabil i ty work, type II activi ty is further enhanced but type I activity will degrade through disuse. This will i n tro duce a proportional m uscle i mbalance that may be deltimental to ultimate performance. Balanced train ing, at all stages of fitness, is the key.

Fitness Components

There are several components to fi tness, and as a tra i n i ng guide the'S' factor l ist (Table 2 8 . 2 ) is usefu l .

Table 28.2

All of the fi tness components are important to some degree for back stabi l i ty, and their importance varies dependi ng on the stage of rehabili tation. Stamina, i n t h i s case represen t i ng local muscle endurance, is important as the holding time of a muscle. Endurance of the back muscles, for example, has been shown to be a predictor for occupational back pain (3,7) and enhanci ng the holding time of stabili ty muscles has been stressed in Chapters 25 and 26. As the subject progresses to weigh t-trai ning, there is a tendency to work for strength rather than endurance, whereas bot h are actually required. I n terms of suppleness, both the range of motion and the resistance to motion are important. With funct ional i nstabi lity, the stabi lizing muscles may lose not only endurance but also their abili ty to work at full in ner range. Perform i ng i nner range holding con tractions therefore forms an i mportant part of i n i t ial stability trai ning and must be extended i n to the weight-trai ning gym. Simi larly, the use of eccentric s trength is important. Again, in many popular weight-tra i n i ng programs eccentric actions are rarely used and concentric actions are focused on. From a stability perspective, concen tric work must be bala nced by an equal emphasis on eccentric (controlled loweri ng) and isometric ( hold ing) muscle work. Speed has an i mportant place to play in back sta bili ty. M uscle reaction speed in response to a force tending to push a joint away from a stable posi tion is a determ i n i ng factor in stabi l i ty of both peripheral joi n ts (6, 1 ) and the spine ( 5 ) . The ability to detect when such movement is occurri ng (proprioception) is an aspect of skill . Practicing more complex activities such as free-weigh t exercises in addition to machine weight-training will enhance movement ski l l . The technique used in a n y exercise w i l l rehearse a speci fic set of actions that come toge ther to make up a m otor program . These actions must accurately reflect the required movement quality t hat is be ing sought by the rehabi l i tation program. Training speci fi c i ty d i c ta tes that the changes occurring in the body as the result o[ exercise will match the technique

The Componen ts of Fitness

Component Title

Meaning

Stam ina Su ppleness Strength Speed Spec ifici ty Spiri t

Cardiovascular a n d local muscle endurance. Range o f motion and resistance to motion Isotonic (concentric and eccen tric ) and isometric strength Rate of movement and m uscle reaction time Tailoring an exercise t o the patients flJllc tional requ irements Psychological features of exercise including [ear of movement

Chapter T\Nenty-Eight: Weight Training for Back Stability

used. There is said to be a specific adaptation to an imposed demand ( t he "SAI D" pneumoni c ) . Rehears ing i ncorrec t tec h n iques w i l l degrade movement qual i ty. For example, the h i p h i nge action i s used to re-educate a patien t's abi l i ty to combjne stabil i ty with pelvic and lumbar movement and to i mp rove general bending and l i f1ing actions. If a squat exer cise is prac t i ced as part of a wei ght-tra i n i n g pro gram, and i f a poor technique is used, t h i s w i l l overflow i n to daily u s e o f bend i n g a n d l i ft i ng and encourage the patient t o use poor techn i q u e i n these actions, i nc reasi n g the risk o f occupational injury. A further aspect o f ski l l t h a t i s i m portant i s removi ng fear of movement, so-called fear-avoi dance (4, 1 6 ) . W i t h chro n i c back pain especial ly, a p a t i e n t may often consider t h a t an a c t i o n ( for example, l i ft i ng or bending) m a y cause pain and therefore avoi d t h i s action. Using movements t h a t i nvolve t hese actions in a l i m i ted and protected way can gradu ally de-se n s i t i ze the pat i e n t and i m prove t h e func tional abili ty.

Weight-Training Methods

Before an in tense exercise program is used, a warm up is recommended . This should prepare the body for increased levels of activity and rehearse any complex actions before performance with weights. The meth ods and effects of warm up are not within the rem i t of this chapter, b u t further i n formation is available elsewhere ( 1 0) . I n general terms, larger muscle groups are worked before smaller muscle groups during weight-training. This is because smaller muscles will tend to fati gue more quickly and so will be a l i m i t i ng factor to train i ng time. Exercises that i nvolve several muscle groups (general exercises) are therefore placed before exer cises Llsing single muscles (isolation exercises) . One exception to this rule is pre-exhaust t raining in which isolation movements are performed first. More complex exerc i ses, and especially free weight exercises that req u i re h igh degrees of skill, shou ld be performed early during a rou t i n e . They are attention demanding and qual i ty will degrade rapidly as fatigue sets i n . M achine exercises are less demand i ng in terms of com plexity and so may be used later in a weigh t-tra i n i ng program . For basic training with inexperienced users, the body parts that are worked should be al ternated, such as arms-legs-tru nk and repeat; this is known as circui t formal. I n this way the muscles worked are allowed an adequate recovery period. As users progress, two further orders may be used. The first is the com-

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69 1

Clinical Pearl

Pre-ex haust t ra i n i ng is a tec h n i que Llsed purely for strength training to dramatically i ncrease the st ress i mposed on a muscle and recru it large-d iameter m uscle fibers. When any muscle con tracts to i ts maximal volun tary contraction ( MVC), the poi n t o f fai l ure is deter m i ned by both central and peripheral mecha n isms. Peripheml mechanisms i nvolve a muscle's physiology and i nc lude such factors as local phosphocreat i ne con centration a n d ATP ava i l ab i l i ty . Cen tral factors al-e largely the responsi b i l i ty of mental processes and include motivation and t he degree o f motor u n i t recru itment. The point of failure that determi nes M VC is often the result of central mechanisms especially i n t he inexperi enced user. A patient may there fore feel that they have achieved theil- max i m u m when in fact they have not. Using pre-exhaust train ing is a met hod of overcom i ng this l i m i tation. Using the gluteal m uscles as an example an isolation movement such as prone lying hip extension is used to the point of MVC. I mmediately after t h is (no rest is allowed) a general exercise such as the squat is used. I f the gluteals were t r'l l ly fat igued the patient would be u nable to perform the squat. By changing the muscle emphasis, however, the muscle is "fooled" into working harder.

pound set ; here, two or more di fferent exercises are used [or t h e same m uscle group. The second is the superset , in which two exercises are chosen that work the same body part but for two oppos i ng muscle groups (agonist and an tagonist). In general terms, h igher repet i tions ( 1 2 - 1 5) with lighter weights are used for endurance traini ng, and lower repet i tions (6-8) with heavier weights are Llsed for s trength . A back stab i l i ty program with weigh ts aims t o bu i l d s trength while maintaining muscle endurance which has already been established by ft-ee exercise. Repe t i t i o n n u m bers i n the region o f 1 0 to 1 2 are t herefore used. Slower movements t hat take greater time will also improve endurance and allow the user more time to attend to postural align men t . Faster movements that take less t i me give a more explosive action and less time is avai lable to at tend to alignment. For this reason, slower, more precise actions are used i n the initial stages of weight training and faster more explosive exercises are only used when alignment i s good and stability has become more automatic and therefore, by definition, less atten tion-demanding. To perform i n tense exerc ise safely, progressive loadi ng is needed. This enables the user to gradually

692

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i m prove the coord i nation required by high-intensi ty muscle work. Several neurogen i c changes i nvolving the motor unit are required, i ncluding enhanced recrui tment, motor unit firing fTequency, synchro n i zation, and d i s- i n h ibition ( 1 0) . These occur i n addi t i on to t h e more complex coord i nation between muscle groups. To i m plement t h i s progression i n tra i n i n g overload, two t o three sets o f exercise repe t i t ions are performed . The first set should be of fairly low i n tensity (40%-50% M VC ) , the second h igher (60%-70% MVC), and the t h i rd h igher s t i l l (800/090% M VC ) . In t h i s way the specific coord i nation i nvolved i n a m ovement i s rehearsed at low i ntens i ty levels be fore maximal muscle work is performed. Also, any alignment fau l ts can be identified at low i n tens i ty levels i n which they are l ess l i kely to cause i nj u ry . The combi n a t ion of sets, repet i t i o n s , a n d weight gives a train i ng volume. F o r example, per forming 3 sets of 1 0 repeti tions (30 movements i n total ) with a weigh t o f 2 0 k g gives a trai n i ng volume of 600 kg. Larger trai n i ng volumes are required for strength and power t raining and smaller volumes for endurance and speed . In the i n i tial stages o f s tabi l i ty trai n ing, exercises are performed regularly throughout the day, on each day, to i ncrease m o tor learn ing. This is because rep e t i t ion is essenti al to progress motor learn i ng fTom the cogn i t ive stages ( understanding the movement) to the motor stage ( movement becoming skillful) and finally to the autonomous stage (action automatic or "grooved"). Th is fTequency of t raining is only possi ble because the muscle work involved is not i n tense and so long recovery periods are not required. W i th weigh t-tra i n i ng, however, tra i n i n g i n tensity (over load) is suffic i en t ly h igh that m icroscopic muscle damage ( cataboli sm) is caused. This i s i n tentional and resul ts i n tissue regrowt h (anabolism) and adap tation. Time is required for t hese tissue adaptations, however, so weigh t-trai n i ng should only be performed on alt ernate days to allow the worked t i ssues to recover. I n general terms, pai n w i l l occur at the t i me of training through local muscle ischemia and later through delayed onset muscle soreness ( D O M S ) . This pai n/sti ffness i ndicates that the muscle i s recoveri ng and a second trai n i n g peri od should not be begun until m uscle pai n has reduced considerably. I f the trai n i ng frequency is too great, recovery w i l l not occur and overtra i n i n g will resu l t . Selecting t ra i n i n g days on Monday, Wednesday, and Friday, for exam ple, with a rest period over the weekend will ensure adequate recovery. For t he experi enced user a "sp l i t routi ne" may be used in which separate m uscle groups are targeted at each tra i n i ng session to all ow a greater t ra i n i n g frequency.

Clinical Pearl

A split rout i ne allows muscles to recovery by exercising d i f reren t muscle groups each day. For example, users can t ra i n 4 days each week providing that on M onday and Thursday they exercise the upper body and upper trunk (scapulo-thoracic) stab i l i ty, and on Tuesday and Friday they work the lower body and lower t runk (lum bar) stability. I n this way the same muscle groups are not worked on 2 consecu tive days, and adequate recov ery is given.

Safety Factors in the Weight Gym

All exercise equipment has risks that must be mini m i zed, and t hese risks fall broadly i n l o two cate gories: t hose associated with movi ng machinery and those associ ated wi th the l i ft i ng action itself. A num ber of simple rul es allow the risks to be m i n i m i zed (Table 2 8 . 3 ) .

Control the Weights

M oving weigh ts carry considerable momentum. Un l ess the weights are kept under con trol throughout the full range of motion, there is considerable risk to joi n ts and body tissues. When a l imb reaches the end of its mot ion range, the l igaments and muscles sur roun d i ng i t become t ight and l i m i t furt her move ment. M ovements that are too rapid lead to loss of con trol-the join t stops movi ng at the end of the motion range, but the i nertia of the weight forces t he j o i n t further against the t igh tening support tissues.

Table 28.3 • • • •

• • •

•

• • • •

Safety Checklist for Weigh t-Training

Always warm up before tra i n i ng C heck mac h i nery before use Set up mach i nery to suit your height and weight Tie back long hair and be caref" clothi ng Remove jewelry Wear serviceable footwear-no fli p-flops! Use correct exercise techniques and keep the weigh t u nder con t rol Watch your body alignment-keep a neut ral, stable spine ' Keep abd Practice good back care-l i ft correctly Train within your own li mi tations Never train through an i nj ury-see a physical therapist ( 1 1 )


I n turn, this may cause overuse injury, or in some cases severe t rau ma. When using weigh t-training equipment, subjects should conti nually be encouraged to control the movemen t of the weight rat her than allowing i t to control them . It is good . practice to decelerate the limb towards the end of a movemen t and avoid hyper extending a joint.

Appropriate Clothing

Even thoLlgh most machines have guards, fingers and especially hair and clothing can be trapped i n t h e moving weight stack w i t h severe results. Subjects should be i nstructed to tie back long hair when they use machine weights and keep loose clothing away from the machi nes. They should remove watches, l arge rings, and dangling jewelry. Good sports shoes wi l l help protect the feet , and the weight gym is no place for beach s hoes or fl i p- fl ops! Toes can be stubbed and free-weights dropped onto feet . In addi tion to protecting agai nst direct injury, good footwear wi l l also keep the feet aligned. Excessive foot prona tion encourages the tibia to inwardly rotate and stress the knee especially on exerc ises such as the squat.

Equipment Adjustment

Most good weight-training machi nes allow users to adjust the unit for the shape and size of t heir bodies. Make sure that the mac hine is set up before it is used, and that the user knows exactly how the machine works before beginning the exercise. Pivot points of mach ines are normally marked with coloured plastic caps. These should be al igned to the center o f rota tion of the joint being exerc ised . Exercising wit h t h e joint axis and machine axis out of l i n e wi l l hamper correct movement and stress joints.

Personal Limits

Subjects must be rem inded to t rain well wi t h i n their limits. An old adage says, "Never sacrifice tec h nique for weight." Lift i ng a weight that is too heavy can i m pair both tec h nique and body alignment and increase the risk of injury. In add i tion, pract icing an incorrect tech ni que wi l l rehearse faul ty movement patterns, wh ich, when they become habitual, are d i f ficul t to mod i fy.

Listen to the Body

Subjects must not train a body part that is i njured unless fol lowing a structured rehabil i tation program. The key is to li sten to the body, espec ially to pain.

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N ever allow an individual to exercise through increas i ng pain . If a movement hurts and is conti nued slowly, t he pain m ay d i mi n ish-i n which case t h e person is probably sufferin g from stiffness that is working loose. If pain i ncreases, however, the movemen t must stop. Remember that some rapid, repeated actions may "reduce" pain simply because the exercise hurts m ore t h a n the i nj u ry (cou nter i rri tant effec t ) or because the subject simply "gets used to the pain" (habituation or desensitization) . Subjects must be warned of this possibility and rem inded to stop such movemen ts immediately i f they even suspect a mask i ng effect.

Postural Alignment i n Weight Training Practice

A subj ect's posture may be described in terms of the l in e of gravity (LO G ) . I n standing, viewed [Tom the side, t h e LOG passes anterior t o the lateral malleo lus, anterior to the knee joint axis , and through the greater trochanter, lumbar, and cervical spines, gleno h umeral joint, and lobe of the ear. From behind, the body is split i n to two equal halves wi th the spine cen t ral and the medial borders of t he scapula vertical and lying approximately t h ree fingers breadths from the LOG . The center of gravity of the human body l i es wit h i n the sacrum ( S 1 I2 level ) . Positioning any weight that is l i fted at t h is level m i n i m izes the forces acti ng on the body by reducing add itional leverage. I f the weight is held at a distance from this poi nt, its poten tially damaging effects are mul tipl ied. For this reason t he pelvis is referred to as the "safe zone" when l i fting in an occupational health environment. Subjects should be encouraged to keep the weight t h ey are l i ft i ng wit h i n or close to the safe zone for as l ong as possible during a weight-trai ning action . A weigh t-training movemen t may take a total of 20 sec onds, for example. I f during this action the weight can be kept c lose to the safe zone for 1 8 o f these 20 seconds, the l i ft is consi derably safer than if it can only be kept close t o the safe zone for 5 of t he 20 sec onds. Clearly, however, the t i me taken to perform the action i s exactly t h e same d ispel l i ng the popular notion t hat "good l i ft i ng takes l onger. " A good l i ft minimizes m uscle work and joint loading and should be performed wit h a h igh degree o f precision and control. Movement of body segments away fTom the LOG introduces a l everage force that m ust be resisted by passive t issue tension and active muscle contraction. In addition, deviation from the LOG al ters joint load ing forces. During weigh t-training the add it ional forces created by the moving weigh t make postural alignment doubly i mportant. Any al teration in l ever-

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age caused by movement of the LOG wil l dramati cally increase t he forces i m posed on the body by trai ning weights. In add i tion, m ovement of one body part away from t he LOG necessi tates movement of a neighboring body part in the oppos i te direction to main tai n balance. Constant repeti t i o n o f i ncorrect al ign ment leads to habitual changes in posture that are difficult to modify.

Rehearsing Correct Alignment Patterns

Correct a l i gnment patterns w i l l have been i nt ro du ced early in the back stabili ty program wit h free exercise. Each pattern is briefly descri bed i n tabu lated form , but more detail is located elsewhere ( l1 ) . I n each case subjects must es tablish the neu tral spine position a nd perform the abdom inal hollow ing action be fore the exercise commences. As t he subject progresses to the weight gym , the basic exer cises must be rei n forced using weight-tra i n i ng appa ra tus for the tra i n ing t o be tru ly spec i fi c . To re in force correct lumbo-pelvi c rhyth m during bend ing the h i p hi nge action is used (Table 2 8 . 4 ) . This may be m od i fied for t h e weight gym by placing a wooden bar across t h e shoul ders ( broom handle), and progressed to a weigh t-training barbel l (Fig. 2 8 . 1 ) . This action t h e n becomes the classic "good morning" exerc i se ( Fig. 2 8 . 2 ) . The action is useful to develop the hip extensors in the presence o f good stabi l i ty. However, when alignment fau l ts creep i n , the leverage a n d poten tial i n tradiscal pressure increase changes a useful m ovement into a poten tially dangerous one. The sternal l i ft movement should be used in both sitting and standing ( Fig. 2 8 . 3 ) . Once the subject is

Table 28.4

•

•

•

28. 1 H ip h i nge.

able to perform the action in isolation to lumbar m ovemen t , the action should be i ncorporated into weigh t-tra i n i ng exerc i ses. Seated rowing actions are u se fu l e i t her using a rowi ng machine wi t h a sternal pad (Fig. 2 8 . 4 ) or usi ng a low pul ley machine ( Fi g . 2 8 . 5 ) . I n each case the subject moves from a posture o f t horacic fl exion and scapular abduction to one of t horacic extension and scapular depres sion and adduction to optimal alignme nt. The opti mal posi t ion is held for 2 t o 3 seconds to emphasize t h e i n ner range con trac tion before lowering the wei gh t.

Basic Alignment Patterns

Sternal Lift •

Figure

I solate thoracic movement fTom lumbar movement Perform thoracic extension to flatten kyphosis Lift sternal rather than expand i ng ribcage (discourage subject from taking a deep brea t h ) Draw scapu lae down and i n (depression and adduc tion)

Hip Hinge •

•

•

•

U nlock knee to reduce stretch on hamstri ngs M a i n tain neu t ral lumbar position, do not alter depth of lordosis An teriorly t i l t pelvis on fixed h i p , m a i ntain i ng relative posi t i ons o f lum bar spine and pelvis Maintain t horacic alignment, avoi d i ng t horacic flexion and scapular abduction

Weight Shift •

•

•

•

Move shoulder girdle and pelvic girdle hori zontally Shift line of gravity from a poi n t between the feet to a point directly over the weight beari ng foot Do not allow shoul ders or hips to "dip" M a i n tain al ignment as leg is li fted


Figure

28.2 Good morning.

Weight s h i ft m ovements (Fig. 2 8 . 6 ) are i m por tant for exercises usi n g si ngle l eg actions such as lunges and hip isolation m ovements ( mult i h i p mac h i ne ) . W h e n t h e subject c a n accurately control h i s/her alignment by s h i ft i n g the pelvis and transferring the LOG over, and away fTom, the weight-bearing leg the subject should progress to resisted h i p movements and lunging. Resi s ted h i p movements may be perform ed usi ng a l o w pulley machine fit ted with an ankle s t rap or a purpose buil t mul t i h i p u n i t (Fig. 2 8 . 7 ) . I n each case t h e i m portant fac tor with respect t o back s tability i s not the leg which is l i ft i ng, but the weight-bearin g leg. I t is essent i al that the subject maintains their align ment over t he wei g h t bearing leg by "sta n d i ng tall" and not allowing the pelvis to dip toward the m ov i ng leg . In the lungi ng action ( Fi g . 2 8 . 8 ) ( i n i tially performed wi thout weights), t he chall enge i s to control t he wei g h t transference t hroughout t he movement wit hout " fall i n g onto" the leading foot or "jumping off" the tra i l i ng leg. The pelvis should move cl ose to a horizon tal l in e i n the sagi ttal plane showing that vertical move m e n t of the body's cen tre of grav i ty i s m i n i m ized. Feedback on alignment can be gained by perform i ng the exercise in fron t of a mirror and comparing the l i n e of the shoulders to the hori zon ta l l i ne . Holding a wooden pole across the s houlders also gives the subject useful feedback

A

B

28.3 (A) Sternal l i ft-start. (B) Sternal li ft-finish. Figure

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696

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A

Figure

28.4 Row ing mac h i n e w i t h sternal pad.

and makes moveme n t contro l easier. As weight pro gression is used, a barbel l may be p l aced across t he sh oulders or dumbbe l l s h e l d i n the hands.

Machine Exercises

A major fea ture o f mac h i n e exercises i s t h a t t hey usually allow only single-plane motions and are

B Figure 28.6 (A) Weight s h i ft start. (B) Weight sh i ft finish.

Figure

28.5 Rowi ng action using low pulley.

therefore easy to coordinate. Pulleys are an excep tion here. Because they allow tri-plane motion, more complex coordination is possible. For each exercise, the fi rst set of movements is used as part of t he warm up to fam i l iari ze the subject with the action.


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For t h i s i n i t i a l set, 12 to ] 5 repet i t ions of a l i g h t w e i g h t ( 30% MVC) are u sed . Two furt her s e t s are performed u s i ng 1 0 to 12 and then 8 to 1 0 repe t i tions w i t h progressively increasing weigh t . For endurance and speed work m a x i m u m weights of 50% MVC are chosen , bu t for strength and power higher weights are used up to 80% M VC. Duri ng t he first set, movements should be slow and controlled . If speed training is to be used, the rate of movement rather than the weight is t hen progressively increased. Si ngle-sided weight-tra i n i ng exercises are described for the right side of the body. Subj ects should per form exercises w i t h both sides of the body, w i t h instructions for the left side bei ng a m i rror o f t hose o n the right .

Lateral Pull-Down

Figure

Figure

28.7 M ultihip unit.

28.8 Lungi ng.

The latissimus dorsi is one of the muscles ( together with the t ransversus abdomi nis and gluteals) that tensions the thoracolumbar fascia, an essential com ponent of stabil ization. I n add i tion, it is an i m portant l i fting muscle and can be strengthened by resist ed adduction, pull i ng the arm i n to the side of the body [Tom an overhead position, or from a forward reach ing position. For the lateral ( "lat") pull-down , the subject low ers the bar e i t her beh ind the shoulders or to sternal level on t he c hest (Fig. 28.9A). Ei ther posi tion can be used. B o t h have advantages and d isadvantages. Pull i ng the bar beh ind t h e neck will i ncrease the subj ec t's shoulder m obi l i ty, because that pos i t i on requi res a h igher degree of external rotation at the shoulder than pull i ng the bar to the ches t . Because external rotation i s often l i m i ted, t h i s is a desirable form of mobi l i ty tra i n i ng. However, the seventh cer vical vertebra has a very promi nent spi nous process and subjects must take care not to st ri ke this point with the bar. To lessen the l i keli hood of this happen ing, they should pass the bar beh i nd the head by 2 to 3 inches ( 5-8 c m ) rather than letting it brush the hair. In t h i s way, the bar w i l l m i ss the cervical spine and come to rest across the shoulders. Ind ividuals unable to adopt this posi tion should pull the bar to the upper chest. The action is a smooth pull down ward , placi ng the bar (in the first case) beh i nd t he neck and across the shoulders. The head should be tilted forward slightly, and the bar must not strike the cervical vertebrae but rest across the m iddle fibers of the t rapezius. The loweri ng action of the weight pulls the bar u p again . I nstruct your subjects not to perm i t the weights to rest toget her at the end o f the movement, so t h a t u sefu l trac tion will be m a i n tained i n the latissimus dorsi and the thoracolum bar fascia.

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reduces the emphasis on the latissimus dorsi and emphasizes the b i ceps brac h i i .

Cable Crossover

A

The cable crossover again works the latissimus dorsi, but this time in conjunction with the pec torali s major. The starting position is with both arms abducted (Fig. 28.10) and the feet slightly wider than shoulder width apart. The action i s to exhale and p u l l both arms i n to the sides of the body. An al ternate approach is to pull t he arms forward across the chest, a technique that increases the adduc tion range and emphasizes the pectoralis major. The elbows should be slightly bent throughout the movement , to reduce stress on the elbow joint. As the weight i s lowered back to i ts starting posi tion, the abduction must be controlled to reduce the s tress o n t h e shoulder j oi n t . Allowi ng the weight t o drop will place a combined abduction and trac tion force on the joint that could potentially damage the rotator cuff muscles and/or the joint capsule and ligaments.

Back Extension (Machine)

B

The back extensors are essential to lifting and bending activities, and their i mportance and retra i n i ng has been covered in Chapter 26. The muscles act both to extend the spine and to balance the flexion moment produced by the trunk and weight being l i fted. In this action t he endurance of the back extensors is a decid i ng factor for poten tial i njury (3,7). In addition the sequencing of the back extensors with the hip exten sors is vital. This sequencing was re-educated by using

Figure 28.9 (A) Lat pull-down to back of neck. (B) Lat pul l-down to fro n t . Narrow grip.

Bri nging t he bar in fron t of t h e body to the top of the sternum reduces the range of extern al rota tion and extension at the s houlder and is especi ally useful for less fl exible i ndividuals and t hose w i t h a h i s tory o f shoulder subluxation or d islocati o n . Subjects m a y u s e w h i c hever grip that seems m o s t comfortable-wide, n arrow, pronated, supinated, or m id position, and al terati o n i n the hand position will change the emphasis o f t he movement. U s i ng a narrow gri p (Fig. 2 8 . 9 B ) e i t her on a standard wide bar or a box frame (wit h elbows in pronated or m i d posi tion) w i l l allow the e lbows to pass close to the sides o f the body as the bar is pulled down. I n body building this is said to t h i c ken the latissimus dorsi ra ther than broaden it ( 1 7 ) . U s i ng a supin ated grip

Figure

28. 1 0 Cable crossover.


hip h inge activi ties. Both the hip extensors and back extensors can be trained usi ng the dead l i ft action, which is a variation on the hip h inge (see later) . The specialized back extension u n i t (Fig. 28.11) enables the subject to isolate the back extensors [Tom the h i p extensors and to i ntroduce l i rn i ted range motion, or to re-strengthen only part of the m ove ment range. The machine should only be used once subjects have mastered pelvic til ting and the hip h inge action i tself. Subjects should adjust the mac h i ne so t hat t h e knees and hips are bent t o 70° t o 80° a n d t h e pivot point of the mach ine is aligned with t he hip joint axis. The movement begins with a posterior tilt of the pelvis, moving the seat contact poi nt from the ischial tuberosi ties back onto the sacmm. The action is move ment of the pelvis on the stationary femur, with the back stabilized and i mmobile throughout the early part of the movement. Only when the second half of the movement range begins should the spine move into extension. I nexperienced subjects often l ose stabi l i ty during t h i s exercise and relax the abdom i na l muscles enabli ng the lumbar spine to hyperextend. It i s vi tal that the neutral pos i t ion of the lumbar spine be maintained throughout the first part of the action.

Back Extension (Frame)

Use of the back extension frame ( Roman chair or back strong) has been covered i n Chap ter 2 7 . The

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concern here is i ts use in the weigh t-tra i n i ng gym (Fig. 28.12A). To ensure correct alignment make sure that the subject m a i n tains the neutral posi tion and performs abdomi nal h ollowing throughout the acti o n . To aid performance with the inexperienced user, place a bench or stool i n [Tont of the mac h i ne, level wit h your subject's shoulders. The subject places h i s/her hands on t he stool in a push-up posi tion, with the l egs locked o n to the mac h i ne pads. I nstruct the subject t o l i ft first one hand and then both hands fTom the stool, placing the arms by h i s sides. O nce the subject can perform t h i s action i n a controlled manner, spinal movement i n to extension may be added. Begin in the neu tral pos i t ion (with or withou t stool support ) , and move i n to extension, l i ft i ng the shoulders approximately 2 to 3 in ches ( 5-8 cm) above the h i p height, and then m ove back to neutral. Finally m ove down i n to fl exion. This action if uncontrolled can place considerable stress on the spinal t issues. At the begi nning o f the movement, if the abdom inal muscles are allowed to relax, the pelvis will anteriorly tilt and the lumbar spine hyperextend, compressing the l u m bar facet joints wi t hout sufficient i nt ra-abdom inal pressure to reduce the load. Back stab i l i ty and good alignment control are t herefore essential pre-requisites for per forming this exerc ise. When a back extension frame is not available the leg curl bench may be used ( Fig. 2 8.12B and 2 8.12C). The weigh t should be set to maximum to provide an immobile fixation poin t . The subject h ooks their feet beneath the mac h i ne pads and l ocks the knees. Abdom inal hollowing should be performed and the body straightened while supporting i t on the fore arms. F inally, the forearms should be li fted from the bench and the body held straight (Fig. 28. 1 2 D ) .

Seated Rowing

Figure

28. 1 1 Back extension machine.

The seated row is used to strengthen t h e scapu lar stab i l i zers and thoracic extensors as a progression t o the sternal l i fL action. In add i t i on , the seated row will work the glenohumeral extensors. The starting pos i t io n (Fig. 2 8. 5 ) is wi t h the k nees bent, to relax the hamstrings and allow the pelvis to anteriorly tilt sufficiently for the l u m bar s p i ne to rem a i n in its neutral posit i o n . The action is to perform a sternal l i fL, extending the t horaci c spine and on this stable base to i n t roduce upper arm extensi on, keeping the e lbows in to the sides o f the body. When the wei g h t i s lowered, the stable base must be mai n tained, making sure that the t horac ic spine i s not forced i n to flexi o n . To effect ively extend the th orac ic spine, abdominal hollowing must be performed and m a i n tained t hroughout the exercise to e l i m i nate

700


A

B

C

0

28. 1 2 (A) Back extension frame. (B) Back extension on a leg curl bench, start. (C) ShOl-t lever. (D) Long lever.

Figure

un wan t ed lumbar extensi o n . The exercise should not be used where a subject is unable t o stabi l ize the lumbar spine, because l u m bar hyperex tension w i l l b e used as a " t r i c k movement" to avoi d t horaci c extension w h i l e pressing the chest forwards a n d upwards.

Single A r m Pulley Row

si ngle arm pul ley row has a s i m i l ar effect to seated row i ng (Fig. 2 8 . 1 3 ) , w i t h t h e addi tion t h a t i t c a n b e used to gain sym me try between the arms by correc t i ng any u n i l a teral i m balance. I n addi tion, it i n t roduces some rotary stabilization or rota tion move m e n t as the t ru n k is a l l owed to twi s t . T h e combi ned move m e n t s i nvolved p resen t a sig n i ficant c hal lenge to the stabi l i zi n g system of the back. The start ing position is a l u nge position to the left o f the pulley, with the l eft foot forward and the D The

Figure

28. 1 3 Single-arm pul ley

ro w .


handle o f the low pulley gripped i n the right hand. The subject should place h i s/her left hand on t he left knee [or support and angle the body forward (trunk on h i p ) a t 45°. The rig h t arm is then pulled into extension at the shoulder and as the pulley hand approaches his chest, t h e tru n k shoul d be rotated slightly to the right, and the thoraci c spine extended, as in the sternal l i ft ac tion. Using a low pulley posi tion ( pul ley at m id-sh i n level ) requ i res the subject to lean over slightly, i ncreasi ng the workload on the spi nal extensors . This is sui table only when alignment is good and the subject can keep the spine straight t hroughout the action. Placing the pul ley at waist height negates the requ i rement to lean forward, taking the workload o ff the spinal exten sors and red ucing leverage on the spine. The waist h igh pos it ion is used if the subjec t's alignment is poor.

Low Pulley Spinal Rotation

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dicular to the direction o f pull, with t he leg closer to the pul ley flexed at the knee. The cable of the pulley i s attached to the flexed knee with a leather or web b i ng strap. The action is to rotate the spine so that the bent knee passes over the s traight leg and onto the floor. In the s i t t i ng posi tion the subject s i ts on a stool ( Fig. 28. 1 4B ) , faci n g perpen dicular to the pul ley, with the left side approx i m ately 1 8 i nches ( 0 . 5 Ill ) from the p ulley. The subject should Oex t h e i r right arm to 90° at the elbow, and hold i t across the body. The low pulley is adjusted so t h a t it is level with t he subjects el bow and the D handle of the pul ley is gripped with the righ t hand. The action i s to rotate the trunk to the right, keeping the h i ps, legs, and arm im mobile so t hat the weight of the pulley u n i t if li fted by the trunk action alone. The s tanding exercise is similar to the s i t t i ng. Agai n , the subject adjusts t h e pulley to elbow level a n d folds the o u t e r arm across the body. The feet are p laced apart to maintain a wide base of support .

The oblique abdo m i nal musc les are i m portant i n controll ing rotary forces act i ng o n the spine during manual hand l i ng especially. Flexion rotation forces tend to be the most damaging to the spine, and sep ara t i ng these two actions provides a safe and effec L ive met hod of restrengtheni ng. The low pulley mach ine is an adaptable u n i t , which is readily avail able. H owever, common resi stance tubing may be subs t i t u t ed when weight-training apparatus i s not avai lable. Lying, silting, or standing start i ng posi tions may be chosen. For the lying (Fig. 28. 1 4A) exercise, the subject begins in a half-crook lying posi tion perpen-

The ro tary torso mach i ne again s trengt hens the oblique abdom i nals but w i t h the added advantage t hat end-range movements m ay be avoided, or parts of the range strengthened in isolation. To begin the movement (Fig. 28. 1 5 ) , the ro tation lock i s posi tioned to al l ow ful l rotation range but not t o over s tre tch the spine. If rotation is pa i n ful or the range is l i m i ted, the machine lock should be posi t i oned to avoid the painful end-range pos i t i o n . The action is a smooth rotation i n to fu l l musc u l ar i n ner range .

A

B

Rotary Torso Machine

Figure 28. 1 4 (A) Low pulley spi nal rotation-lying. (B) Low pulley spi nal rotation standi ng.

702

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m inis does not bulge outward or "bowstri ng" duri ng the action, so abdominal hollowing is a vital pre cursor to t h i s exercise. To begin , the subject grips the machi n e arms, holding the elbows in through out the action. The i nstruction should be to " roll into flexion," keeping the back on the backrest and avoiding the tendency to lean forward. The movement begins by p u l l i ng the sternum down rather than for ward . The eccentric componen t of the movement is i m portant , so l owering the wei g h t has to be slow and controlled. When the lower rollers provi de lower abdom inal work, the pelvis is posteriorly tilted to cause the hips to l i ft slightly before the t runk is flexed. In this way the whole of the rectus is worked .

Trunk Flexion with High Pulley (Pulley Crunch)

Figure

28. 1 5 Rotal"Y torso mach ine.

The subject should hold the positIOn and then slowly re lease it, avoiding the tem p ta t i on to drop the weights rapidly and spin the machi ne. Reset t he m ac h i ne for t h e oppos i te rot a t i o n , rememberin g t h a t range and s trength are not necessarily sym metrica l . Add i tionally, the ful l i nner-range posi t i on i n to which an i n d i vidual's muscles can p u l l t h e spine ( physiological i n ner range) i s generally less than the fu l l inn er range i n to which it can be taken pas sively (anatomical i nner range). As long as t he motion i s smooth and not too fast . the subject i s i n n o dan ger o f overly s tressi n g t h e facet j o ints o f t h e spine duri n g t h i s exerci s e . I f the m o t i o n is too rap i d , however, t he momentum o f the mach i n e can take the spi ne pas t p hysiological i nner range and i nto anatomi cal i n ner range, load i n g the facet j o i n t s un necessarily.

Trunk flexion m ay also be performed on a h igh pul ley mac h i ne ( Fig. 28.1 7 ) . The subject should ei ther kneel (2-point kneeli ng) or sit, with t heir back to the machine, holding the D handle of the mac h i ne in both hands behind or in Front of the neck (ei ther is correct-the subject should choose the most com fortable position ) . Encourage the subject to sh uHle forward u n t i l the slack in the mach ine cable has been taken up. The action is to flex the trunk alone rather than the trunk on the h i p ( hip h i nging). The correct movement is encouraged by taking the head down ward t oward the knees rather than forward in front of the knees. The action must be slow and con trolled. Because very l i ttle movement is avai lable, i t i s essential t hat the machine cable i s tight before the action begins.

Abdominal Mach ine

Several abdomi nal mach ines are avai l able on the market, but most provide res is ta nce to t ru n k flex ion, emphasizing the supraumbili cal port i on of the rectus abdom i n i s . Some provide addi tion a l resis tance [or the h i p flexors working the i nfraum b i lical port ion o f the rectus abdo m i n i s as well (Fig. 28.1 6 ) . If possible, a l i gn t h e pivot of the machi ne w i t h t h e cen ter or l ower portion o f the l umbar s p i ne rather than the hips. It i s i m portant that the rectus abdo-

Figure

28. 1 6 Abdominal mac h i ne.


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momentum, which are potentially i n j u rious. To min i mi ze the risk of i njury the followi ng prerequ isi tes m ust be met: •

•

•

•

•

•

Show good stab i l i ty and alignment . Have good e ndurance o f stab i l i ty muscles (see chapter 2 7 ) . Have mastered t h e mac h i ne weight exerc ises described. Have performed a warm-up and stretched before each weight session. I n i t i ally be supervised until their exercise tec h n i que is good . W i t h i n the context of a back stabil i ty program, your subjects should perform all the free-weight exercises progressively and non competit ively.

Basic Free-Weight Exercises Figure

28. 1 7 Tru n k Oexion with h igh

pul ley.

Free-Weight Exercises

In the context of a back stabil ity program, [Tee-weights are used only for subjects who have heavy demands for strength and speed. Generally this implies i ndividuals who perform ei ther medium or heavy manual han dling as part of t heir job, or who are i nvolved in stren uous sports. Free-weights are particularly useful i n t hese groups a s part o f l ate-s tage rehab i l i tation because of the complexity of skills that free-weights require in comparison with machine weights. I n general, free-wei ght exerc ises may be seen as a progression on machine weight exercises as those help build the s trength needed in t hese more com plex free-weight m ovements. Subjects must per form the exercises i n t h i s sect i o n u nder strict supervision until they have perfected t h e act ions. Speci al consideration should be give to subj ects younger than 1 8 or older than 60 years of age because bone formation and j o i n t structures is generally more prone to i nju ry. These i ndividuals should exerc ise only under the supervision o f a p hysical therapist or trai ner who is speci ally t ra ined to teach these groups.

Special Concerns Regarding Free-Weights

Because [Tee-weight exercises combine both speed and weigh t , they expose the body to h igh levels of

For the i n i ti al free-weight exerc ises, the movem ents should be slow and well controlled. Exerc ises to develop "explosive power" are described l a ter, and form a progression on the free-weight m ovements. Because free-weight exercises require more balance and coord ination than mac h i ne exercises, less weight should be used . Prescribe approxi mately 1 0 to 1 2 repe t itions for each exercise, using a fi nal weigh t that is comfortable for that n umber of repet i tions ( i . e . , i f the i ndividual can perform 20 repetitions, the weight is too light; if he/she can perform only 5 rep etitions, i t is too heavy). For each exercise, t h e sub ject should perform 2 or 3 sets of 1 0 to 1 2 repeti tions. Use a m oderate weight ( perhaps hal f the final weigh t) for the first set, three-quarters of t he final weight for the second, and the f"ul l weight only dur ing the t h i rd set. In this way, the muscles gradually become accustomed to handli ng the weigh t , as the subject increases h is/her skill o f movement. Subjects should rest after each set u n ti l their breat h i ng rates and heart rates return to normal-never let them start a fresh set w h i le their hearts are pou nding or they are out of breath. I njury is far more l i kely i f a subject is fatigued. As a guide, 2 or 3 sets for each exercise should be performed, three sessions per week, res t i ng at least one day between sessions. After 2 weeks , subjects may i ncrease the target weight, aga i n accord i ng to how much they can l i ft com fortably. Let them follow this program-2 or 3 sets of 10 to 1 2 repe t i tions, three sessions per week-for a period of at least 16 weeks, never i ncreasing the weights to the points where they feel exhausted.

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the upper arm and chest of the subject as the arms are lowered. A l ig h t barbell (approximately 2 2 . 53 2 . 5 1 b, or 1 0- 1 5 kg) i n held in the hands (over grasp) beneath the bench. The subjec t may hold her elbows either close to the sides of her chest or with arms abducted t o 90°-th e narrow pos i t ion places greater work on the l atissimus dorsi, whereas the wider grip emphasizes the posterior deltoids and scapular stabilizers. The action is to pull the bar upwards towards t he u nderside of the bench in a single slow, smooth movement, and at the same time to extend the tho racic spine by performi ng the sternal l i ft action. The movement is paused i n the upper posi tion for 2 sec onds and t hen the bar is lowered.

Dumbbell Row

Figure 28. 1 8 Lying barbell

row.

Lying Barbell Row

This exercise strengthens the shoulder retractors and hel ps to increase t horacic spine extension and in so doing may be used in kyphotic posture correction. Because the subject lies on a gym bench, the l um bar spine is prevented from hyperextending, a faul t often seen in other rowi ng exercises. The subject l ies prone on top of a gym bench (Fig. 2 8 . 1 8 ) , which is narrow enough to allow free arm movem e n t . A bench which i s too wide will dig into

The dumbbell row is a single-handed movement, and as such may be used to help correct asymmetry between the should retractors on ei ther side of the body ( Fig. 2 8 . 1 9). Typically, asymmetry may be iden t ified by a subject's i nabil i ty to lift the same amount of weight , or to perform the same n umber of repeti tions, with each arm . The subject begins in a hal f knee l i ng position on a gym bench , with the right arm and right knee on the bench and the left leg straight with the left foot on the ground. The subject grips a dumbbell (whatever weight feels comfortable) with his left hand, t hen pulls ( l i fts) it toward h i m/herself, brushing the side of his body with the elbow. The movement should be stopped when the dumbbell approaches the chest. As the subject pulls the upper arm i n to extension, the scapula is adducted and the t horacic spine fla ttened (extended ) . The inner-range

Figure 28. 1 9 Dumbell

row.


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position should be held for 2 to 3 seconds before low ering the weight under con trol.

Good Morning

The good morning exercise is basically a h i p h i nge movement performed with a weigh t (Fig. 28. 2 ) . I t works t h e spinal ex tensors statically a n d t h e h i p extensors dynam ical ly, and a s such is an excellent movement to develop l i fl i ng capac i ty. It is essential for the subject to have mastered the hip h i nge action before perform i ng t his exercise. The subject begins by s tandi ng with the feet j ust wider t han shoulder-wid th apart . The knees should be unl ocked sligh lly ( patella over the center o f the foot ) to relax the hamstrings and allow free pelvic t i l l . With a l ight barbell (approxi mately 2 2 . 5 lb, or 1 0 kg) across the shoulders, the subject t i l t s her pelvis interiorly ( maintai ning the neutral position of the spine) so that her t runk angles forward to 45°. The subjects should be supervised closely to ensure that t hey do not allow the spine to flex, moving the axis of rotation fyom the h i p joint to the m i ddle of the spine-this stresses t h e spine considerably, both increasing intradi scal pressure and overstretch ing the posteriorly placed soft t i ssues.

Squat

The squat is a fundamental movement in weight training, and one that can usefully teach correct spinal alignment and strengthen the quadriceps, hamstrings, and gluteals ( Fig. 28.20). However, it is also a move ment t hat is often performed i ncorrec tly placing stress on the lumbar spine. Correct techn ique and close supervision is therefore essential. To ensure good technique, t he subject should prac t ice the action using a light wooden pole (e.g., broom handle) until the tech n i que is perfected. The begin ning weight should be 10% to 30% o f body weight, dependi ng on body build-stronger subjects can use the larger value. I deally, subjects should always use a squat rack, so that the bar can be taken in the standi ng position. Feet should be shoul der-wid t h apart, with t h e toes turned ou t sligh t ly. T h e subject steps under the bar, wi th the h i ps d i rectly u nder his/ her shoulders. Gripping the bar with hands slightly wi der than shoulder width apart, the subj ect places it across the back or the shoulders (over t he posterior deltoids and trapezius ). The sternal left action should be performed to coun teract the tendency for the bar to push the subject's thoracic spine i nto flexion. Both legs are straigh tened to left the bar off the rack-then a small step is taken backward to clear t h e bar from the rack.

Figure 28.20 Squat.

Throughout t he movement, the subject should l ook up and keep the spine nearly verti cal . The action is to flex the h i ps and knees simul taneously, keeping the weight of t he body and bar over the center o f the foot rather than the toes. Instruct the subject to lower the bar u nder con trol until the t h ighs are parallel to the groun d . After a momentary pause in this lower position to assist balance, t h e action is reversed to l i ft the bar. Close supervi sion should be maintained to ensure that the upward movement is con trolled (no i nc rease in speed toward t he end of t he act i o n ) and that her knees s tay over the foot rat her than m oving apart or toget her.

Barbell Lunge

The squat was said to be one of t h e basi c m ove ments i n weight-tra i n i ng. H owever, it has the d i s advantage t h a t i t subjects the spine to com pression forces that m ay not be sui table for subj ec ts with dis cal lesions within the lumbar spi ne. I n these cases especially, the barbell lunge is i m portant ( Fig. 28.8). I t offers a similar leg motion t o the squat, but as a si ngle leg movement is used, less weight is required . The weight reduction results in correspondingly less spi nal compression. The s tart posi tion is with the bar across t he shoul ders as for the squat. Because only one leg leads the movement , less than h a l f the weight of a squat is used . The subject stands with the feet shoulder-wid th

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apart, with the fee t marking the end of an i maginary rec tangle on t h e floor (shoulder-width wide and twice shoulder-width long). As in the squat, the sub ject performs a sternal left action while maintaining spinal alignment. Instmct h i m to step d i rectly for ward with the right l eg (as though placing the foot a long the long edge of the rectangle). The knee of the leading leg is bent so that it just obscures the foot, and that of the trailing leg moves toward the ground, stopp i ng when it is 2 to 4 i nches ( 5- 1 0 cm) above the floor. The side of the trail i ng knee should be 6- 1 4 inches ( 1 5-3 5 c m ) from the i n ner edge of the heel of the l eading foot . To s tand u p again, the subject pushes off the lead i ng l eg, bringing the leading foot back to its shoulder-wi d t h start posi tion. The movement must not i nvolve " fa l l i ng" i n t o t h e l ower pos i t i o n o f "j u m p i ng" i n t o t h e upright pos i t i o n . Throughout the m ovement, t h e subj e c t s h o u l d look up and forward , and t h e b a r should remain h ori zontal. In addition, as the body i s low ered i n t o the deep p os i t i o n , the knee should stop sh ort of the fl oor. I t the movement is too rapi d , t here is a danger t h a t t h e subject w i l l s t r i ke the k nee aga i n s t the floor i nj u ring the patella or pre patella bursa.

Free-Weight Exercises for Explosive Power

One of the goals of a stabil i zi n g program i s t o re- i n state the contro l o f neu tral s p i n a l position during daily tasks , sport , and attentio n-demanding actions. The requi res t h a t the subject re-Iearns t h e abi l i ty to stabi l i ze t h e s p i n e w i t h l ittle attention to move m e n t , with the stabi l i za t i on becoming auto matic once more. This stage o f t ra i n i ng represents t he tertiary p h ase o f motor l earn ing, called t h e "autonomous stage" or s tage of automatic action (9, 1 0). The free-weigh t exerc ises i n t h i s section are attention-demanding and consist of several com bi ned movements in func t ional patterns i nvolving l i fting. To perform t hese exercises, your subjects must have progressed t h rough the ful l back stabil i ty program and have good segmental control and spi nal alignment . They should h ave mastered t he machine exercises and basic free-weight exercises i n the previous section of t h i s chapter. Have them rehearse all of the power movements using a wooden pole fi rst , to ensure that their lumbar sta bili zation is good. Although you should still prescribe 2 or 3 sets of 1 0 to 1 2 repeti tions, the fi rs t set should be with an empty bar to be doubly sure that the tech nique is cor rect and to train the muscles in the correct move-

ments. Your prim ary guide for subsequent sets must be spinal alignment rather than the amount of weight the subject can comfortably lift . If alignment is degraded, stop the exercise and reduce the weight, even if the subject feels the resulting weight is "too light." Emphasize to the subject that the aim here is rehabi l i tation, not competi tive weight l i fting or body sculpting.

Hang Clean

The clean action is one of the fundamental power movements used in weight-training ( Fig. 28.2 1 ). Here, i t is described in stages to introduce the subject to the movement progressively. The Hang clean forms stage ( i ) of this sequence. The subj ec t begins with the barbell ( held with hands pronated) resting on the m iddle of t he thighs. For t h i s exercise the i nstructor should hand the bar to the subj ect, who is already in the basic position i l lustrated by (Fig. 28.2 1 A) . The subjects body should be angled forward (30°-45°) at the h ips, and the spine must be straight , with the lumbar spine i n its neutral position. Knees and hips s hould be flexed, ankles dorsiflexed. The action is divided into two phases: the upward movement and the catch. During the upward movement, t he subject holds his/her tru n k erect and l i fts the bar explosively in a single "jump" action, extending the h ips and knees and plantar-flexing the ankles, without allowing her feet to come off the ground . The shoulders should stay directly over the bar, and the path of the bar should be as c lose to the body as possible. At the point of maximum plantar-flexion of the ankle, the shoulders will begin to shmg to continue i n the upward path of the bar ( Fig. 2 8 . 2 1 B) .

A

B

Figure 28.21 Hang clean. Reprinted wi t h permission from Norris C M . Back Stab i l i ty. H u man Kinetics. Champaign, IL, 2000.


During the catch phase, which fol lows the shoul der shrug as a continuous motion, the subject main tains the upward movement by flexing the arms. The elbows drop u nder the bar, forcing the wrists i n to extension to allow the bar to rest on the now hori zontal palms ( Fig.e 2 8 . 2 1 C ) . The elbows p o i n t directly forward , a n d t h e bar rests over the anterior aspect of the shoulders. As the bar touches the shoul ders, the subject should slightly flex the knees and hips to absorb shock and prevent a sudden jolt of the bar on the shoulders. The bar is lowered to the ground, by reversi ng the sequence of actions-the subject dips beneath the bar by bending the knees slightly, and then allows the elbows to drop, with the bar staying close to the body as i t is lowered. The knees should bend so that the body is not pulled into spinal flexion as t he bar approaches the ground.

Power Clean

The power c lean represen ts stage ( i i ) of the power movemen t and is only used when the power clean has been mastered ( Fig. 28.22). The movement now is to l i ft the weight from the floor rather than from the t highs. The barbel l rests ei t her on the floor or on two racks approxi mately 1 0 to 20 i nches (25-50 cm) high. The subject begins standing with the feet shoul der-width apart and knees inside the arms. The feet are flat and turned out sl ight ly. I t is i m portant with this exercise that the subject wears supportive t ra i n ing shoes-preferably a weigh t-lift i ng boot or high cut cross training shoes with broad, stable heels. The subject grasps t he bar with hands slightly wider than shoulder-wi dth apart, arms straight . H e/sh e should squat down so that the shins are almost in contact with the bar, knees over t he center of the feet, and shoulders over or slightly i n fTont of the bar ( Fig. 28 .22A). A common error with this movement is to

Figure 28.22 Power clean. Reprinted with permission

[yom Norris C M . Back Stab i l i ty. Human Kinetics. Champaign, IL, 2000.

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get closer to the bar by flexing the spine, using only l i m i ted knee and hip flexion. H owever, this markedly i ncreases t he stress on the spine and must be avoided. The l i ft consists of t hree uninterrupted phases. First phase-the subj ect extends the knees and move the hips forward as the shoulders are rai sed. The shins should stay back (a common error with novices is to h i t the knees w i t h the bar), always mainta i n i ng the alignment of the back. The l i n e of the bar's move ment should be vert ical , with the heels staying on the ground and the bar passing close to her body (Fig. 28.22B). The shoulders should s tay back, either over or slightly i n front of the bar, and the head should be positioned to look straight ahead or slightly up. Sec ond p hase-for the "scoop," the subject drives the h ips forward, keeping the shoulders over the bar and allowing the elbows to extend fully. The trunk is nearly vertical at this stage ( Fig. 28.22C). This move ment brings the bar to t he m idpoint of the thighs. Third p hase-the exercise cont inues as i f i t were the hang clean, through the upward movement and catch phases of that exercise (see i l lustrations for hang clean). The action is one of continuous movement, with no significant pauses between sections. Although the bar maintains i ts momentum, the subject should never lose control of the movement. The bar should be lowered i n a vertical path, bending the knees to preven t the spine from being pulled into flexion.

Dead Lift

The dead l ift is a progression on the hip h i nge move ment, which now adds weight and a pulling action to the basic movement learnt previously. The dead l i ft is an excellent exerc ise to develop back and hip strength, and to add the power needed for general l i fting actions ( Fig. 2 8 . 2 3 ) . T h e exercise begin s w i t h the b a r o n the floor ( novices may use low racks at first, until they gain control through the ful l range of the exercise ) . Your subject should stand with their feet flat on the floor ( heels must not l i ft ) and shoul der-width apart. The knees are positioned i nside t he arms, gri pping t he bar w i t h hands pronated and sligh tly wider than shoulder-width apart. The el bows poi n t out to the sides, to allow unimpeded movement as they bend during the l ift. Some athletes prefer to use an al ter nate grip, with one forearm pronated and the other supinated ( knuckles down). I f the subject finds this grip more comfortable, by all means let h i m/her use it, but suggest t h a t they alternate which hand is pronated and which supi nated to maintain a bal anced arm muscle development. The subject should position the bar over the balls of the feet, al most touching the shins. The shoulders should be over or

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Figure 28.23 Dead I i rt .

sl igh t ly ahead of the bar and they spine al igned in i ts neu tra l posi lion. The movement begins by extending the knees and driving the hips forward. At t he same t i me, your sub ject raises his shoulders so that the al ignment of h is back remains unchanged. The path of t he bar is ini tially vert ical , and i t is held c lose to the body at all ti mes. The elbows must not bend, because t hat will cause a loss of power, and t he shoulders should stay over or slightly in front of the bar. The head should be placed so that your subject looks forward . Feet should remain flat. As the knees approach full extension, the back begins to move on the hip ( h i p h i nge action), maintaining spi nal alignmen t . Have your subject lower the bar with a squat motion, still maintaining the spine erect, keeping the bar close to the shins.

force generation) and endurance ( main tenance of contraction), and as faster movements are used the adaptation i nvolves changes in power ( ra te of work performance) and muscle reaction speed . For gen eral usage, and recrealional sport the weight-training act i ons used above are su fficient to build power. For clien ts who participate in higher levels of sports com pet i t ion, however, or who simply want greater fitness gains, plyometric exerc ises spec i fic power exercises called plyometrics are necessary. Plyometric exercises en hance power development by cap i t a l i zing on the stretch-sh orten cycle. Rapid actions are used that i nvolve an eccentric action fol lowed by a concentric contraction. Elastic energy results from passive stretching of the elastic compo nents of the muscle during the eccentric p hase. I n addi tion the speed of stretch invokes a stretch ( myo tactic) reflex, which i tsel f generates add itional force. The combination of passive and act ive force genera tion sum mates to give a greater power outpu t . T o creat e max i m u m power w i t h concentri c eccentric coupli ng, the subject must be warmed up; and a rapid eccentric movement must be followed i m mediately by a rapid concentric movement with no rest between the two phases. Any standard exer c ise can be performed in t h i s way, but not all exer cises should be included in a plyometric workout because leverage forces and momen tum acting on the spine can be dangerous. Subjects should beware especially of rapid end range motion on the spi ne and long lever movements. An addi tional feature of t he use of rapid movements in a stability program is muscle reacl ion time. Once a certain strength has been gained in a muscle, further strength gains do not necessarily lead to enhanced function. The abil i ty of a muscle to react quickly and stabilize a joint before it is pushed out of alignment is also vital. Such rehabili tation has been used effectively with the ankle (6) and knee ( 1 ) and it seems l i kely that similar activit ies wou ld be beneficial to the spine.

Before You Start

Power Training Using Plyometrics

I n i tial ly, back s tabil i ty exercises focus on m uscle i so lalion and slow con trol led actions to develop t h e holding (endurance) abi l i ty o f the core muscles. Weigh t-training mai n ta i ns this core work, but adds work for the global m uscles which res ist the ten dency of forces to displace the spine [Tom i ts neutral pos i t i on . I n i t ially, these m ovements themselves are slow, and basic in their complexity, but gradually the complex i ty o f movements is enlarged and the speed of movement increased . The i nitial muscle adapta tion in stabi lity t ra i n i ng is one of s trength ( maximum

Before progressi ng to the fol lowing plyometric exer cises, your cl ients m ust •

•

•

Demonstrate good basic s tabi l i ty-be able to perform the basic stabi l i ty exercises covered in Chapter 26. Demonst rate good power and control in the trun k-be able to perform gym ba ll exercises covered in Chapter 26. Have good overall general fi tness demonstrated by regular, moderate to-intense exercise over the previolls 6 to 8 weeks.


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back stabi l ity ( Fig. 2 8 . 2 5 ) . The subject s tands fac ing the punch bag, then pushes t h e bag with one or both hands. H e/she should fol low t h e movement t h rough, using t runk flexion only, to 45°. The sub ject re mains in this flexed pos i t i o n , and, as the bag swi ngs back, takes t h e bag wi t h h i s arm s s t raight ( bu t un l ocked) and flexes the arms, exten d i ng his trunk m i nimally and transferring h i s body we ight to h i s back foot to cushion the momentum o f t he mov ing bag.

Twist and Throw with Medicine Ball Figure 28.24 Plyometric side bend.

Plyometric Exercises

For eac h of the exercises make sure that the subj ec t is closely supervi sed until the correct technique is seen consi stently. The movement should be stopped if t he exercise technique or back stab i l i ty is seen to degrade. Subjects should perform eac h exercise ( for both right and left sides of the body if a m ovement i s asymmetrical) a maximum of 20 times p e r session. They should try fTom one to three sessions per week for at least 8 weeks, gradually increasing the speed of their movements as t hey are able. After the 8-week period, subjects may stop using plyometrics unless they are com pet i t ive ath letes who require explosive strength to aid performance-i n which case their strength coach should prescri be t h e advanced p ly ometric exercises, tai loring them to the athletes' par t i CLdar sports or events.

Plyometric Side-Bend Using a Punching Bag

The twi st and t h row develops power and speed of the trunk rotators (Fig. 2 8 . 2 6 ) . The subject shoul d stand in an al igned posture, with the trunk stabi l i zed using mini mal abdom i na l h o l l owing. A training partner, faci ng i n the same direction as t he subject, stands approximately 3 feet to the right, holding a medicine bal l . While the subject rotates her trunk to the rig h t ,

A

This movement develops power and speed of the trunk side flexors while main taining back stabil i ty (Fig. 28.24). Instruct the subject to stand with his/her left side toward a punching bag, feet shoul der-width apart, wi th h is left arm abducted to 90°. The subject should flex his/her t runk to the left and push (not h i t ) the bag wi th t h e straigh t arm , t hen side flexes to the right to decelerate the swing of t he bag (stopping short of full range). The left side flexion begins t he motion again. The action is reversed with the subject standing wi t h his righ t side toward the bag.

Plyometric Flexion and Extension Using a Punching Bag

B

This punch bag exercise develops power and speed i n the trunk flexors and extensors while mai n tain i ng

Figure 28.25 (A) Plyometric nexion/extension , start.

(B) Flexion/extension, finish.

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described elsewhere ( 1 1 ). Here, i t is being used as a plyometric action on ly. Instruct both the subject and h i s training partner to lie on a mat with t heir knees bent (crook, or hook lying) , such t hat their ankles are almost touching. They should then raise their trunks (without sign i ficant ly movi ng their legs) to a stable upright position. The train i ng partner throws a med icine ball to the subject, who catches it while in the u pright posi tion, holding it close to his chest. The subject then moves back i nto the lower trunk curl position. He should stop the movement short of ful l range ( h is back should not touch the ground), then "bounce" back wit h a concentric trunk curl and throw the bal l back to his partner. I ncrease the range of the curl i ng action by having the subject lie over a cush ion-this allows the trunk to move i n to exten sion before m oving into flexion. Be sure that move m e n t stops short of ful l range in each direction to reduce joint loading.

Leg Raise Throw Figure 28.26 Twist and t h row.

her part ner throws the medicine ball to her. As she catches the bal l , she should rotate to t he left, pre stretch i ng the oblique abdom i nals. She stops the movement short of ful l range, rotates back to the righ t , and throws the bal l back to her partner.

The leg raise action h as been heavily criticized as an exercise for the i nexperienced user ( 1 1 ) . However, for the el i te athlete, is has a use to develop power and speed in the lower abdom inals ( Fig. 28.28). The action described performs a leg raise fTom a hanging position. This exercise must not be used fyom a lying posi tion. For a kinesiological comparison between t hese two movements see ( 8 ) . The movement must be strictly supervised, and the poten tial shearing forces

Medicine Ball Trunk Curl

The tru n k curl is a modification of a s tandard sit-up action ( Fig. 2 8 . 2 7 ) . It i s designed to reduce t h e a c t i o n o r the h i p flexors a n d t o work t h e rectus abdom ini s muscles upon a stable abdominal base by m i n i m ally contract i ng the deep abdo m in a l mus cles throughout the movement. The exercise i tself is

Figure 28.27 Medicine ball truck curl .

Figure 28.28 Leg raise t hmw.


on the lumbar spine recogn ized. Before performi ng the action using a medicine bal l , supervise the action as the subject moves the legs unloaded. Only if align ment is excel lent should loading be added . The subject should hang fTom a gym n'!-sium beam wi th a ball beneath h i m . Ins truct him to gri p the ball between both feet, t hen flex his hips and spine to throw t he ball forward to a wai ting partner. The part ner places the ball back between you r client's feel while the hips are still flexed to 90°. Your client then lowers his legs to pre-stretch the l ower abdomi n als before repeating the movemen t .

• CONCLU S I O N

Both local a n d global muscles should b e trained to en hance stabi I i ty of the s p i n e . The use of weigh t traini ng i s thus clinically useful a s well a s practical . Weight-trai ning for back stability is an excellent final progression of a stabil i ty program , or an adjunct for those individually currently training in a gym as part of a general fitness regime. One of the essential ques tions that this chapter has addressed is "when to move a patient fTom floOl- exercise for s tability ( fTee exercises and gym bal ls) to weight based exercise (machines and fTee-weigh ts)." The answer is, i t depends on when the patient demonstrates appropriate motor control to sta bilize the neutral spine position required for safe train ing. Much of the material for this chapter is based on Norris (2000), to which t he reader is refen-ed for fur ther information.

Audit Process


Describe how to determine a patient's readiness to progress to heal t h club exercises.

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How would you incorporate stability principles i n to health club exercises?

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How can i n tensity, sets, and repet it ions be varied to achieve strength t ra i n i ng goals?

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Give advice about how to exercise safely using the popular weight-tra i n i ng machines fou n d in most healt h c lubs.

•

What are safe and unsafe techniques for t ra i n i ng squats?

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• REFERENCES 1 . Beard, DJ , Kyberd PJ , O'Connor n, Fergusson C M , Dodd CAF. Reflex hamstring contraction latency i n anterior cruciate l igament deficiency. J Orthop Res 1 994; 1 2 : 2 1 9-22 8 . 2 . Bergmark A. Stab i l i ty o f the l um bar spine. A study in mechanical engineeri ng. Acta Ort hop Scand 1 989; 230(suppl ):20-24 . 3 . Biering-SOI-ensen F. Physical measurements as risk i nd icators of low back trouble over a one year period. Spine 1 984;9: 1 06-1 1 9 . 4. Crombez G, Vlaeyen, JWS, Heu ts P H TG , Lyens R. Fear of pain i s more disabl i n g t han t he pa in i tselr. Evidence on the role of pai n-related fear in chronic back pain d isabi l i ty. Pain 1 999;80:329-340. 5 . Hodges PW, Richardson CA. Contraction of trans versus abdominis i nvariably precedes movement of the upper and lower l i mb. I n Proceed ings o f t he 6th i n temational conference of the I n ternational Federation of Orthopaedic M a n i pu lative Therapists. Lillehammer, Norway. 1 996. 6. Konradsen L, Ravn JB. Ankle i nstabi l i ty caused by prolonged peroneal react ion time. Acta Orthop Scand 1 990;6 1 (5):388-390. 7 . Luoto S, Heliovaara M , Hurri H, Alaranta H. Static back endurance and the risk o f low back pai n . C l i n Biomechanics 1 99 5 ; 1 0:323-324. 8 . Norris C M . Abdom inal m uscle tra i n i ng in sport. B r J Sports Med 1 993;27 : 1 9-2 7 . 9. Norris C M . Spin al stabil ization . Physiot herapy J . 1 995;8 1 ( 2 ) : 1 -39 1 0. Norris CM. Sports i njuries. Diagnosis and Manage ment. 2nd ed. Oxford: Butterv.IOrth Hei nemann, 1 998. 1 1 . Norris C M . Back Stab i l i ty. H u m an Kinetics. Champaign, IL, 2000. 1 2 . Richardson C, Jull G , Hodges P , H ides J. Therapeutic exercise for spinal segmental stabil i zation in low back pain. Edinburgh: Churc h i l l Livi ngstone, 1 999. 1 3 . Saal JA, Saal JS. Nonoperative treat ment o f herni a ted lumbar intervertebral disc with rad iculopathy. Spine 1 989; 1 4:43 1 -437. 1 4. Sale D G . Neural adaptation to strength training. Strength and powel- in sport. In: Kom i PV, ed. r o c medical publication, Blackwell Scien tific; Oxford, 1 992. 1 5 . Taylor JR, O'Sul livan P. Lumbar segmental instabi lity: pathology, diagnosis, and conservative managemen t . I n Twomey LT, Taylor J R, eds. P hysical Therapy o f the low back, 3 r d e d . New York: Churc h i l l Living stone, 2000. 1 6. Vlaeyen, JWS, Linton SJ . Fear-avoidance and its consequences i n chronic m uscu loskeletal pai n . Pain 2000;85:3 1 7-332. 1 7 . Weider J . Ulti mate bodybu ildi ng. Chicago: Contemporary books, 1 989.

Advanced Stabilization Training for Performance Enhancement

=

Micheal Clark

Introduction What Is the Core? Core Stabilization Training Concepts Postural Considerations Guidelines for Core Stabilization Training

Learning Objectives

After reading this chapter you should be able to understand: • •

Stabilization

The difference between isolated uniplanar strengthening and functional multiplanar

Strength Power

The stabilization-strength-power continuum

strengthening •

How to progress elite athletic patients to core strength and power exercises

712

Chapter Twenty-Nine: Advanced Stabilization Training for Performance Enhancement

Introduction To bridge the gap between science, and practical appli cation the clinician needs to follow a comprehen sive, systematic, and integrated functional approach

prehensive functional program, the clinician must fully understand the functional kinetic chain. To

713

Benefits of Core Stabilization Training •

Improve dynamic postural control

•

Ensure appropriate muscular balance and joint

when training, reconditioning, and/or rehabilitating a client (see Chapters 5, 26, and 32). To develop a com

--

arthrokinematics •

Allow for the expression of functional strength

•

Provide intrinsic stability to the lumbo-pelvic-hip

understand the functional kinetic chain, the clinician

complex, which allows [or optimum neuromuscular

must first understand the definition of function.

efficiency of the rest of the kinetic chain

Function is integrated, multidimensional movement

(6). Functional kinetic chain training is a compre hensive approach that strives to improve all compo nents necessary to allow a client to return to a high level of function. The clinician must understand that the kinetic chain operates as an integrated, interde pendent, functional unit. Functional kinetic chain training and rehabilitation must therefore address each link in the kinetic chain and strive to develop functional strength and neuromuscular efficiency. Functional strength is the ability of the neuromus cular system to reduce force, produce force, and dynamically stabilize the kinetic chain during func tional movements upon demand in a smooth coordi nated fashion (6). Neuromuscular efficiency is the ability of the CNS to allow agonists, antagonists, syn ergists, stabilizers, and neutralizers to work effi ciently and interdependently during dynamic kinetic chain activities (11). Traditionally, training and rehabilitation have focused on isolated absolute strength gains, in iso lated muscles, utilizing single planes of motion. How ever, all functional activities are multi-planar (MP) and require acceleration, deceleration, and dynamic stabilization (3,4,17,18,20,26,3 4). Movement may appear to be one-plane-dominant, but the other planes need dynamic stabilization to allow for opti mal neuromuscular efficiency (12,29,35,41). Under standing that functional movements require a highly complex, integrated system allows the clinician to make a paradigm shift. The paradigm shift focuses on training the entire kinetic chain utilizing all planes of movement, and establishing high levels of functional strength and neuromuscular efficiency

(3,4,17,18,20,26,34).

What Is the Core? The core is defined as the lumbo-pelvic-hip complex

(25,40,44,46,49). The core is where our center of gravity is located and where all m ovement begins. There are 29 muscles that take their attachment to the lumbo-pelvic-hip complex (40,46). An efficient core allows for maintenance of the normal length tension relationship of functional agonists and antagonists, which allows for the maintenance of the normal force couple relationships in the lumbo pelvic-hip complex. Maintaining the normal length tension relationships and force-couple relationships allows for the maintenance of optimal arthrokine matics in the lumbo-pelvic-hip complex during func tional kinetic chain movements. This provides optimal neuromuscular efficiency in the entire kinetic chain, allowing for optimal acceleration, deceleration, and dynamic stabilization of the entire kinetic chain dur ing functional movements. This provides proximal sta bility for efficient lower extremity movements (2,7,9,

19,20,21,22,23). The core operates as an integrated functional unit, whereby the entire kinetic chain works syner gistically to produce force, reduce force, and dy namically stabilize against abnormal force. In an efficient state each structural component distributes weight, absorbs force, and transfers ground reaction forces (44). This integrated interdependent system needs to be trained appropriately to allow it to h.mc tion efficiently during dynamic kinetic chain activi ties (Fig. 29.1).

A dynamic core stabilization training program is an important component of all comprehensive func tional training and rehabilitation programs. A core stabilization program will improve dynamic postural control, ensure appropriate muscular balance and

Core Stabilization Training Concepts Many individuals have developed the functional

joint arthrokinematics around the lumbo-pelvic-hip

strength, power, neuromuscular control, and muscu

complex, allow for the expression of dynamic func

lar endurance in specific muscles that enable them to

tional strength and improve neuromuscular efficiency

perform functional activities (3). However, few people

throughout the entire kinetic chain (3,4,14,15,17,18,

have developed the muscles required for spinal stabi

26,28,31,34,36,45).

lization (19,20,23). The body's stabilization system

714

--


I Optimum Length-Tension Relationships

I

-

I

Efficient Core

I

Muscular Balance

t I I

I I

Optimum Force-Couple Relationships

t Optimum Neuromuscular Efficiency

I Optimum

-

Arthrokinematics ---

I

t Acceleration, Deceleration Dynamic Stabilization

t Injury Prevention

Figure 29.1 Core stabilization concepts.

has to be functioning optimally to effectively utilize the strength, power, neuromuscular control, and mus cular endurance that they have developed in their prime movers. If the extremity muscles are strong and the core is weak, then there will not be enough force created to produce efficient movements. A weak core is a fundamental problem of inefficient movements that leads to injury 0,2,3,13,19,20,23,33,37,3 8,43). The core musculature is an integral component of the protective mechanism that relieves the spine of deleterious forces that are inherent during f,1nctional activities (9,48). A core stabilization training program is designed to help an individual gain strength, neu romuscular control, power, and muscle endurance of the lumbo-pelvic-hip complex. This approach facili tates a balanced muscular functioning of the entire kinetic chain. Greater neuromuscular control and sta bilization strength will offer a more biomechanically efficient position for the entire kinetic chain, therefore allowing optimal neuromuscular efficiency through out the kinetic chain. (3,17,18,26,28,32,34,45). Neuromuscular efficiency is established by the appropriate combination of postural alignment (static/ dynamic) and stability strength, which allows the body to decelerate gravity, ground reaction forces, and momentum at the right joint, in the right plane, and at the right time (6). If the neuromuscular sys tem is not efficient, it will be unable to respond to the demands placed on it during functional activi ties (11,13 , 20,23, 24). As the efficiency of the neuro muscular system decreases, the ability of the kinetic chain to maintain appropriate forces and dynamic stabilization decreases significantly. This decreased neuromuscular efficiency leads to compensation and substitution patterns, as well as poor posture during

functional activities (11,28). This leads to increased mechanical stress on the contractile and non-con tractile tissue, leading to repetitive microtrauma, abnormal biomechanics, and injury (1,2,5,10,12,41, 47). To fully understand functional core stabilization training and rehabilitation, the clinician must hJlly understand functional anatomy, lumbo-pelvic-hip complex stabilization mechanisms, and normal force couple relationships. (6) (see Chapter 5).

Postural Considerations The core functions to maintain postural alignment and dynamic postural equilibrium during functional activities. Optimal alignment or each body part is a cornerstone to a functional training and rehabilitation program. Optimal posture and alignment will allow for maximal neuromuscular efficiency because the normal length-tension relationship, force--couple rela tionship, and arthrokinematics will be maintained during functional movement patterns (Fig. 29.2) (11, 40,44,46). If one segment in the kinetic chain is out of alignment, it will create predictable pallerns of dys function throughout the entire kinetic chain. These predictable patterns or dysfunction represent the state in which the body's structural integrity is compro mised because segments in the kinetic chain are out of alignment. This leads to abnormal distorting forces being placed on the segments in the kinetic chain that are above and below the dysfunctional segment (1,2,11,39,41,44,47,49). To avoid these patterns and the chain reaction that one misaligned segment creates, we must emphasize stable positions to maintain the structural integrity of the entire kinetic

Chapter TlNenty-Nine: Advanced Stabilization Training for Performance Enhancement

--

715

Kinetic Chain Imbalance

I

I I

I

Altered

Altered

Altered

Length-Tension Relationships

Force-Couple Relationships

Arthrokinematics

t

I

I

Altered Sensorimotor Integration

t Optimum

Neuromuscular

t Figure

29.2 Kinelic chain

Altered Movement Pattern

imbalance.

chain (28). A comprehensive core stabilization pro gram will prevent the development of selial distortion palterns and provide optimal dynamic postural con trol during h.tnctional movements. Before a comprehensive core stabilization program is implemented, an individual must undergo a com prehensive assessment to determine: muscle imbal ances, arthrokinematic deficits, core strength, core neuromuscular control, core muscle endurance, core power, and overall function of the lower extremity kinetic chain. It is beyond the scope of this chapter to present a comprehensive kinetic chain assessment (see chapters 10, 11, and 34). The interested reader can also review the National Academy of Sports Med icines Kinetic Chain Assessment home study course for a thorough explanation (www.nasm.org).

Guidelines for Core Stabilization Training Before performing a comprehensive core stabilization program, each individual must undergo a compre hensive evaluation to determine the following: muscle imbalances, myokinematic deficits, arthrokinematic deficits, core strength/neuromuscular control/power, and overall kinetic chain function. All muscle imbal ances and arthrokinematic deficits need to be cor rected before initiating an aggressive core-training program. (5,3 8,39). When designing a functional core stabilization training program, the clinician should create a pro prioceptively enriched environment and select the appropriate exercises to elicit a maximal training response (6). The exercises must be; safe, challenging, stress multiple planes, incorporate a multi-sensory

environment, be derived fTom fundamental move ment skills, and be activity-specific (Table 29.1) (see also NASM-OPT Guidelines-www.nasm.org). The clinician should follow a progressive func tional continuum to allow optimal adaptations. The following are key concepts ror proper exercise pro gression: slow to fast, simple to complex, known to unknown, low force to high force, eyes open to eyes closed, static to dynamic, and correct execution to increased reps/sets/intensity (NASM Training Guide lines-www.nasm.org). The goal of core stabilization should be to develop optimal levels of functional strength and dynamic stabilization. Neural adaptations become the focus of the program instead of striving for absolute strength gains (17,43,45,48). Increasing propriocep tive demand by utilizing a multi-sensory, multi modal (Tubing, Bodyblade, physioball, medicine ball, power sports trainer, weight vest, cobra belt, dumbbell, etc.) environment becomes more impor tant then increasing the external resistance (14,15,30,31). The concept of quality before quantity is stressed. Core stabilization training is specifically designed to improve core stabilization and neuro muscular efficiency. You must be concerned with the sensory information that is stimulating your CNS. If you train with poor technique and poor neu romuscular control, then you develop poor motor palterns and poor stabilization (11,19,20,23). The focus of your program must be on function. To determine if your program is functional, answer to following questions; Is it dynamic? Is it MP? Is it multidimensional? Is it proprioceptively challeng ing? Is it systematic? Is it progressive? Is it based on f"l11c 1 tional anatomy and science? Is it activity spe cific (NASM Guidelines-www.nasm.org)?

716

--


------

Table 29.1

--

Exercise Training Variables Lower

Upper

Plane of

Body

Base of

Extremity

Extremity

External

Balance

Motion

Position

Support

Symmetry

Symmetry

Resistance

Modality

Sagittal Frontal Transverse Combinalion

• • • •

• • • • • • •

•

•

Supine Prone Side-lying Sitting Kneeling liz Kneeling Double leg Standing Alternate leg standing Single leg standing

•

•

•

•

Exercise Bench Stability Ball Balance Modality Other

• •

• •

•

•

2-Leg Staggered Stance I-Leg 2-Leg Unstable Staggered Stance Unstable I-Leg Unstable

• •

• •

2-Arm Alternate Arms I-Arm l-Arm wi Rotation

• • •

• •

•

• •

Barbell Dumbbell Cable Machines Tubing M edicine Balls Power Balls Bodyblade Other

• •

•

•

•

•

• •

•

Core Stabilization Training Guidelines

Floor Sport Beam liz Foam Roll Reebok Core Board Airex Pad Dyna Disc BOSU Proprio Shoes Sand

Core Stabilization Training Functional Continuum

•

Progressive

•

Systematic

•

Activity-Specific

•

Integrated

•

Proprioceptively Challenging

•

Based on Current Science

•

Muitiplanar (3 planes or motion)

•

Multidimensional

•

Utilize the entire muscle contraction spect:-um

•

Utilize the entire contraction velocity spectrum

•

Manipulate all acute training variables (sets, reps, intensity, rest intervals, rTequency, duration)

Program Variables • •

Plane or Motion

Exercise Selection Criteria •

reps, tempo, time

Speed or Execution

•

Range or Motion

•

Loading Parameters

Acute Variables (sets,

Safe

•

Challenging

•

Progressive

•

Systematic (Integrated Functional Continuum)

•

Proprioceptively Enriched

•

Activi ty-Specific

under tension, duration) •

Body Position

Bodyblade, sports

•

Frequency

trainer, weight vest,

•

Amount or Control

dumbbell, tubing, etc.)

•

Amount of Feedback

(physioball, power ball,

•


Slow

•

Known

•

Stable

•

Low Force

•

Correct Execution

�

71 7

kinetic chain (14,15,28,31) (see Chapters 27 and 28). See Figures 29.4 to 29.17.

Exercise Progression Continuum •

--

Fast �

�

Unknown

Controlled �

�

Power

Dynamic Functional

High Force �

Increased Intensity

There are 3 levels of training within the National Academy of Sports Medicine's Optimum Performance TrainingTM model including Stabilization, Strength and Power. A proper integrated core stabilization training program follows the same systematic pro gression (Fig. 29.3 and Tables 29.2 and 29.3). (NASM Guidelines).

Stabilization In the stabilization level of core training, exercises involve little joint motion through the lumbo-pelvic hip complex. These exercises are designed to improve the functional capacity of the deep stabilization mech anism (9,36,42,43,48) (see Chapters 5, 25, and 26).

In the power level of core trammg, the exercises involve the entire muscle action spectrum and con traction velocity spectrum during integrated func tional movements. These exercises are designed to improve the rate of force production (3,4,18, 26, 32,34,45) (Figs. 29.18 to 29.24).

• CONCLUSION A core stabilization program should be an integral component for all individuals participating in a func tional training and/or rehabilitation program. A core stabilization training program will allow an individ ual to gain optimal neuromuscular control of the lumbo-pelvic-hip complex and allow the individual with a kinetic chain dysfunction to return to activity much faster and safer.

Audit Process

Self-Check of the Chapter's Leaming Objectives Strength

How does power training differ from strength

•

In the strength level of core training, the exercises involve more dynamic eccentric and concentric movements through a full range of motion. The specificity, speed, and neural demand are also pro gressed in this level. These exercises are designed to improve the neuromuscular efficiency of the entire

training? How does strength training differ from stabilization

•

training? Give examples of how functional training involves

•

the entire kinetic chain?

STRENGTH

STABI LlZATION Three Levels of Progression in the Optimum Performance Training™ Model

Figure 29.3 Three levels of progression in the optimum perfor mance training'" model.

718

--


Table 29.2

CST

Example: Integrated Core Stabilization Program

I-Beginner/Slow/Stabilization

2-Intermediate/Moderate/Strength

3-AdvancediFastiPower

Core Stabilization Supine Progression - Single-Leg Slide - Single-Leg Lift - Double-Leg Slide - Double-Leg Lift Prone Progression - Gluteal Squeeze - Cobra - Leg Raise - Arm Raise - Opposite Arm/Leg Bridging Progression - 2 legs - Marching 4-Point Progression - Drawing-In - Arm Raise - Leg Raise - Arm Leg Raise Iso-Ab Progression - Prone - Prone with Ext - Prone with Abd - Side-lying Cable Progression - Supine - Bridging - Kneeling - Standing

Core Strength CablelTubing Progression Stability Ball Progression - Crunch - Bridge - Curl - Hip Extension - Pullovers - Reverse Crunch - Knee Ups - Russian Twists - Push-Up with Roll

Core Power Medicine Ball Progression - Pullovers - Soccer Throws - Chest Pass - Rotation Pass - Oblique Throw - Back Throw - Overhead Throw

Table 29.3

Bench Progression - Reverse Hyper - Reverse Crunch - Knee-Ups - Side Sit-ups - Back Extension - Back Extension with movement Cable Progression - Chops - Lifts - RotaLions - Combinations Dumbbell Progression - MP Lunge/Curl/Press

- Squat Press - MP Step Press

Ac u te Variables

I-Beginner/Slow/Stabilization

CST

Reps

Sets

Tempo

Rest Int.

Frequency

Duration

12-20

1-3

4-2-1 Iso=5-10 seconds

0-90 seconds

2-4 times per week

4-6 weeks

2-Intermediate/Moderate/Strength

CST

Reps

Sets

Tempo

Rest Int.

Frequency

Duration

8-12

2-4

3 -2- ]

0-60

2-4 Limes per week

4-6 weeks

3-AdvancediFastiPower

CST

Reps

Sets

Tempo

Rest Int.

Frequency

Dill"ation

8-12

2-4

1-1-]

0-60 seconds

2-4 limes per week

4 weeks

For more information on how Lo use this information in a complete system for all clients, please inquire abouL our courses (wvvw.l1as111.org)


A

A

B

B

c

c

Figure 29.4 Ball pullover (A-C).

Figure 29.5 Ball pushup hands on noor with roll (A-C).

--

719

720

--


A

A

B

B

Figure 29.7 Cable chop. (A) Start. (B) Finish.

c

A

D

B

Figure 29.6 Ball Russian twist (A-D).

Figure 29.8 Cable lift. (A) Start. (B) Finish.

Chapter T\Nenty-Nine: Advanced Stabilization Training for Performance Enhancement

A

A B

Figure 29.9 Cable rotation. (A) Start.(B) Finish.

B

A

c

Figure 29.1 1 Lunge to balance overhead press (A-C).

B

Figure 29.1 0 Knee ups (A,B).

--

72 J

722

--


A

A

......

B

Figure 29.1 2 Reverse crunch with rotation (A,B).

A

B

Figure 29.1 3 Reverse crunch with ball (A,B).

B

Figure 29.14 Reverse hypers (A,B).

A

B

Figure 29.1 5 Reverse hypers on ball (A,B).

Chapter T\Nenty-Nine: Advanced Stabilization Training for Performance Enhancement

A

c

B

Figure 29.16 Squat to overhead press (A-C).

A

B

c

D

Figure 29.1 7 Step up fTontal curl press (A-D).

A

B

Figure 29.1 8 Back extension throw. (A) Start. (B) Finish.

--

723

724

--


A

8

Figure 29.19 Medicine ball pullover on gym ball (A,B).

A

8

Figure 29.20 Medicine ball fTont oblique throw. (A) Start. (B) Finish.

A

8

Figure 29.21 Medicine ball chest pass. (A) Start. (B) Finish.


A

B

c

o

E

throw (A-E).

Figure 29.22 Medicine ball overhead

--

725

726

--


A

A

B

B

Figure 29.24 Medicine ball soccer throw (A,B).

c

Figure 29.23 Medicine ball rotational chest press (A-C).

• REFERENCES I. Beckman SM, Buchanan TS: Ankle inversion and

2.

3.

4.

5.

hypermobility. Effect on hip and ankle muscle elec tromyography onset latency. Arch Phys Med Rehabil. 76(12):1138-1143,1995 Bullock-Saxton JE. Local Sensation Changes and Altered Hip Muscle Function Following Severe Ankle Sprain. Physical Therapy. 1994; 74(1):17-23 Caraffa A, Cerulli G, Projetti M, et al.Prevention of an terior cruciate ligament injuries in soccer.A prospec tive controlled study of propliocpetive training. Knee Surg Sports Traumatol Artrhrosc. 1996; 4(1): 19-21 Chimera NJ, Swanik KA, et al. Effects of plyometric training on muscle-activation strategies and perfor mance in female athletes. J Athl Train. 2004; 39(1):24-31 Cibulka MT, Sinacore DR, Cromer GS, et al. Unilat eral hip rotation range of motion asymmetry in patients with sacroiliac joint pain. Spine. 1998; 23(9):1009-1015

6. Clark MA. Integrated Training for the new millen nium. National Academy of Sports Medicine.Cal abasas; 2000 7. Cresswell AG, Grundstrom H, Thorstensson A: Observations on intra-abdominal pressure and pat terns of abdominal intra-muscular activity in man. Acta Physiol Scand 144:409-418,1992 8. Cresswell AG, Oddson L, Thorstensson A: The influ ence of sudden perturbations on trunk muscle activ ity and intra-abdominal pressure while standing. Exp Brain Res 98:336-341,1994 9. Crisco J, Panjabi MM. The intersegmental and multi segmental muscles of the lumbar spine.Spine. 1991; 16:793-799 10. Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprains on dorsiflexion range of motion, poste rior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002; 32:166-173 11. Edgerton VR, Wolf S, Roy RR. Theoretical basis for patterning EMG amplitudes to assess muscle dys function. Med Sci Sports Exerc. 1996; 28(6):744-751 12. Ford KR, Myel' GD, Hewett TE. Valgus knee motion during landing in high school female and male bas ketball players. Med Sci Sports Exerc. 2003; 35(10):1745-1750 13. Fredericson M, Cookingham CL, Chaudhari M, et al. Hip abductor weakness in distance runners with ili otibial band syndrome. Clinical Journal of Sport Med. 2000; 10(3):169-175 14. Garcia FJ, Grenier SG, McGill SM. Abdominal mus cle response during curl-ups on both stable and labile surfaces. Phys Ther. 2000; 80(6):564-569 15. Hahn S, Stanforth D, Stanforth PR, Philips A.A 10 week training study comparing resistaball and tradi-


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17.

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25.

26.

27.

28.

29.

30.

31.

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32. Luebbers PE, Potteiger JA, et al. Effects of plyometric training and recovery on vertical jump performance and anaerobic power.J Strength Cond Res. 2003; 17(4):704-709 33. Luoto S, Heliovaara M, Hun-i H, et al.Static back endurance and the risk of low back pain. Cinical Bio mechanics. 1995; 10:323-324 34. Mandelbaum BR, Silvers HJ, Watanabe D, et al.Effec tiveness of a neuromuscular and propriocpetive train ing program in preventing the incidence of ACL injuries in Female Athletes. American Ol-thopedic Society of Sports Medicine.2002 35. McClay I, Manal K. Three-dimensional kinetic analysis of running: Significance of secondary planes of motion.Med Sci Sports Exerc. 1999; 31:1629-1637 36. Mills JD, Taunton JE. The effect of spinal stabilization training on spinal mobility, vertical jump, agility and balance.Med Sci Sports Exerc.2003; 35(5):S323 37. Nadler SF, Malanga GA, Bartoli LA, et al. Hip muscle imbalance and low back pain in athletes: influence of core strengthening.Med Sci Sports Exerc.2002; 34(1):9-16 38. Nadler SF, Malanga GA, Feinberg JR, et al.Functional performance deficits in athletes with previous lower extremity injury.Clin J Sport Med.2002; 12(2):73-78 39. Nicholas JA, Marino M.The relationship of injuries o[ the leg, foot, and ankle to proximal thigh strength in athletes. Foot and Ankle.1987; 7(4):218-228 40. Neumann DA.Kinesiology of the Musculoskeletal Sys tem; Foundations for Physical Rehabilitation.St. Louis: Mosby; 2002 41. Nyland J, Smith S, Beickman K, et aI.Frontal plane knee angles affects dynamic postural control strategy during unilateral stance.Medicine Science Sports and Exercise.2002; 34(7):1150-1157 42. O'Sullivan PB, Twomey L, Allison GT. Evaluation of specific stabilizing exercises in the treatment of chronic low back pain with radiological diagnosis of spondylosis and spondylolysthesis. Spine. 1997; 22(24):2959-296 7 43. O'Sullivan PB, Twomey L, Allison GT. Altered abdomi nal muscle recruitment in patients with chronic back pain following a specific exercise intervention.J Orthop Sports Phys Ther. 1998; 27(2):114-124 44. Panjabi MM. The stabilizing system of the spine. Part I: Function, dysfunction, adaptation, and enhance ment. J Spinal Disord. 1992; 5:383-389 45. Paterno MV, Myer GD, Ford KR, Hewett TE. Neuro muscular training improves single-leg stability in young female athletes.J Orthop Sports Phys Ther. 2004; 34:305-316 46. Porterfield JA, DeRosa C: Mechanical Low Back Pain; Perspectives in functional anatomy. Philadelphia, WB Saunders 1991 47. Powers CM.The influence of altered lower extremity kinematics on patellofemoral joint dysfunction: A the oretical perspective. JOSPT.2003; 33(11):639-646 48. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J.The relation between the transversus abdominus muscles, sacroiliac joint mechanics and low back pain; Spine 27(4):399-405, 2002 49. Sahrmann S.Posture and muscle imbalance. Faulty lumbo-pelvic alignment and associated musculolskele tal pain syndromes: Ol1hop Div Rev- Can Phys Ther. . 1992; 12:13-20

Nutritional Considerations for Inflammation and Pain

David Seaman

Introduction Neurophysiology and Biochemistry of Nociception Hyperalgesia and Allodynia Pain Is Never "Mechanical"

Diet as a Driver of Inflammation and Pain Insulin Resistance and Inflammation Free Radicals and Inflammation

Learning Objectives

After reading this chapter, you should be able to understand: •

How inflammation affects nociception

•

How diet predisposes a person to inflammation

•

How pH and inflammation are related

•

Omega-6 Fatty Acids and Inflammation Potassium, Magnesium, Dietary pH Regulation, and Inflammation

728

•

The value of supplementation as an alternative anti-inflammatory How fatty acids affect inflammation

Chapter Thirty: Nutritional Considerations for Inflammation and Pain

Introduction

Biomechanics and biochemistry are very different and, lherefore, practice methods related to biochem islry, such as nUlrition, are often difficult to apply for one whose orienlation is biomechanics. This chapter is written lo help the mechanically oriented practi tioner to use nUlrition more effectively, and it begins with a general discussion about pain mechanisms related lo biomechanics and biochemistry. The pro duction or inflammatory mediators represents the biochemical changes that ignite pain mechanisms, and research has demonstrated that many dietary factors augmenl lhe expression of inflammation. In this chapler, two pro-inflammatory metabolic imbalances are described, including insulin resistance and [Tee radical activity. The specific pro-inflammatory dielary imbalances discussed herein include the following: increased omega-6 fatty acid intake, inadequale potassium intake, inadequate magnesium inlake, and inadequate phytonutrient intake. Basic dietary and supplement recommendations are also discussed.

Neurophysiology and Biochemistry of Nociception

Group IV afferents and our other sensory fibers (group I, II, III afferents) are referred to as first-order neurons. Group IV afferents are the most abundant of our sensory fibers and represent the majority of our nociceptive fibers (41,70). They begin in the periphery wilhin musculoskeletal and visceral tissues and they travel to the spinal cord where they synapse with and stimulate second-order neurons in the spinal cord dorsal horn, which become part of the spinothalamic lracl that ends in the lhalamus. From there, thala mocortical fibers, our lhird-order neurons, transmit nociceplive information to the limbic system where pelipheral noxious stimuli may be realized as pain. In other words, the experience of "pain" is approximately three neurons removed from the original reception of the noxious stimuli. Thus, nociception is the reception of noxious stimuli by group IV afferents, and pain is the corlical realization of such stimuli. It is a great error to equate nociceplion with pain. Group IV afferents are nerve cells or neurons, and like all other cells, they have biochemical receptors on their cell membranes. All of our inflammatory mediators, such as prostaglandins, leukotrienes, bradykinin, serolonin, and cytokines, have their own individual receplor on the cell membrane of the group IV afferenl. When spinal tissues are injured, inflammatory mediators are liberated from tissues and cells and bind to their respective receptor sites on local group IV afferents. The receptors for inflam matory mediators are coupled to sodium channels,

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729

such that when mediators bind to their receptors on group IV afferents, sodium channels open, and sodium rushes into the neuron, resulting in an action potential that is ultimately realized as pain (l 1,91).

Hyperalgesia and Allodynia

When inflammation persists, group IV afferenls are brought closer to threshold, such that innocuous mechanical stimuli associated with activities of daily living become painful. It is important to understand that inflammatory mediators "preload" or "sensitize" group IV afferents, bringing them very close to thresh old, which then allows for innocuous stimuli to be realized as pain. In clinical practice, we encounter a sensitized nociceptive system whenever gentle/normal palpation and normal movements are experienced as tender and painful. Hyperalgesia and allodynia are terms that refer to pain induced by a sensitized group IV afferents. Hyperalgesia refers to abnormally intense pain that is induced by a painful stimulus that would, under normal circumstances, be merely painful. Allodynia is pain that occurs in response to an innocuous stimu lus, such that normal movements or normal palpation is experienced as pain, which is a common clinical encounter (90).

Pain Is Never "Mechanical"

The presence of allodynia can lead practitioners to assume that pain is mechanical in nature. When red flags are not present, and when movements associated with normal activities cause back pain, we commonly refer to it as "mechanical" low back pain. While move ments and palpation represent mechanical stimuli, the generation of pain with normal mechanical stim uli is typically caused by the sensitization of group IV afferents by biochemical mediators of inflammation. Clearly, pain is never purely mechanical. Pain is always mechanical, biochemical, and psychological (91), and we should not arbitrarily view one as more important than the other. Complicating the matter a little further is the fact that mechanical, biochemical, and psychological factors are l ikely to be different [Tom patient to patient, and even different within the same patient depending on the balance of stressors present at a given time (90).

Diet as a Driver of Inflammation and Pain

The inflammatory process occurs after tissue injury and needs to occur after injury if healing is to take place. Clearly, inflammation is part of the healing

730

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process; however, chronic inflammation represents a lack of tissue healing and actually, promotes ongoing tissue damage. Cancer, heart disease, hypertension, Alzhei mer disease, endometriosis, osteoarthritis, rheumatoid arthritis, diabetes, aging, osteopbrosis, chronic obstructive pulmonary disease, and meno pause are examples of conditions that develop and exist as a consequence of chronic inflam mation (7,8, 13, 26, 38, 58, 60, 61, 63, 67, 68, 77, 80, 84,94, 95, 97, 104), and this is likely the case for chronic musculo skeletal pain (23,42,57,62,92,98). Standard physiology and pathology books are responsible for providing us with a segmented view of inflam mation. In response to tissue injury, local cells release pro-inflammatory and anti-inflammatory mediators, the balance of which should lead to the resolution of infla m m ation and facilitate tissue repair. Physiology and pathology texts do not alert us to this fact or that an excess of pro-infl a m m atory mediators will lead to chronic inflammation and chronic disease (92). Standard texts also do not alert us to the fact that dietary imbalances are responsible for creating a diet-induced, pro-inflam m atory state that leads to chronic inflam mation (92). Humans are genetically adapted to eat a diet that consists largely of vegetation (fruits, vegetables, and nuts) and animals that ate vegetation, which repre sents what is commonly refen"ed to as a Paleolithic or hunter-gatherer diet (16-18,74). In contrast, our modern diet is based largely on grains, animals that ate grains, refined starches, soda, and engineered

Table 30.1

foods. Table 30.1 l ists anti-inflam matory and pro inflam matory foods. Several dietary imbalances result from the con sumption of our modern diet that promotes a pro inflammatory state, such as excessive omega-6 fatty acid intake, inadequate potassium intake, inadequate magnesium intake, and inadequate phytonutrient intake. Related diet-driven metabolic imbalances including insulin resistance, a prediabetic state, and free radical mechanism s are also known to drive inflammation. A concise discussion of each follows. Before continuing, readers should be aware that the aforementioned dietary imbalances occur simultane ously, are interrelated, and appear to have a cumula tive effect, especially in those who are particularly genetically susceptible to a chronic inflammatory dis ease such as cancer, heart disease, and diabetes (19). Thus, taking magnesium or vitamin E supplements, for example, as a single intervention, will not thor oughly address the diet-induced pro-inflammatory state and is not likel y to impart a significant protective or anti-inflammatory effect. In other words, we can not live on pro-inflam matory foods and expect a single pill, drug, or supplement to have an appreciable anti inflammatory effect.

Insulin Resistance and Inflammation

Insulin resistance represents a prediabetic state referred to as syndrome X or the metabolic syn-

Anti-inflam matory and Pro-inflammatory Foods

Anti-inflammatory Foods

Pro-inflammatory Foods

Fruits Vegetables Nuts Potatoes Fresh fish Wild game Grass/pasture-fed meat Omega-3 eggs Organic extra virgin olive oil Organic coconut oil Organic bu tter Dark chocolate Stout beer Red wine Balsamic vinegar Spices: ginger, turmeric, garlic, oregano, m arjoram, cumin, etc.

Refined grains Whole grains Grain/flour products Grain-fed meats/eggs Most packaged foods Most processed foods Deep fried food Trans fats (margarine, and in most packaged/processed foods) Corn, safflower, sunflower, soybean oil Most com mercial salad dressings

Chapter Thirty: Nutritional Considerations for Inflammation and Pain

drome. If patients have three or more of the follow ing risk factors, they are said to have syndrome X: fasting glucose of �110 mg/dL; triglycerides of �150 mg/dL; HDL cholesterol 35 inches for women (24,105). Syndrome X is thought to be promoted by a chronic systemic low-grade inflammation (14). Type 2 diabetes is referred to as "pro-inflammatory cytokine-associ ated disease" (78). Tumor necrosis factor-a (TNF), one of many pro-inflammatory cytokines, is released by both white cells and adipocytes, and as individuals gain additional fat weight, there is an increased release of adipocyte-derived TNF, which serves to inhibit insulin receptor activity that leads to insulin resistance (32,38). As insulin resistance develops, it promotes glycosylation of proteins and DNA, enhances free radical formation (79), and leads to an upregulation of inflammatory protein production (29), and through these mechanisms, insulin resis tance wIll lead to a worsening of inflammation, which leads to a vicious cycle of chronic inflamma tion (32). Not surprisingly, insulin resistance is involved in the pathogenesis of many pro-inflammatory dis eases such as diabetes, atherosclerosis, stroke, myocardial infarction, and cancer (30,38). In one study (30), 208 apparently healthy, nonobese sub jects were evaluated 4 to 11 years after baseline measurements of insulin resistance were made to determine the incidence of various clinical events including hypertension, coronary heart disease, stroke, cancer, and type 2 diabetes. The subjects were divided into tertiles of insulin resistance at baseline, and the development of clinical events was compared among these three groups. A total of 40 clinical events occurred among 37 subjects, including 12 with hypertension, three with hyper tension and type 2 diabetes, nine with cancer, seven with coronary heart disease, four with stroke, and two with type 2 diabetes. In contrast, no events occurred in the insulin sensitive tertile. The pervasiveness of insulin resistance should not be underestimated, because more than 40 million American adults seem to be affected by the syn drome (49), with some estimates reaching as high 75 million Americans (32). The incidence of syn drome X-driven or related diseases is quite high and far and away represent the major health problem in the United States and other Westernized nations (19). This suggests that a significant percentage of patients needing spinal rehabilitation will have syndrome X. Whether syndrome X promotes back pain has yet to be studied; however, it is interesting to note that the

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731

same mediators that promote syndrome X are also released from damaged spinal tissues. Consider, for example, that syndrome X is pro moted by TNF and is associated with increased lev els of other pro-inflammatory cytokines such as interleukin-6 (IL-6) (78). Intriguingly, increased lev els of TNF, IL-6, and interleukin-l (IL-l) have been found in facet joints of patients with degenerative conditions of the lumbar spine (48). In fact, TNF appears to be a pivotal mediator in disc herniation induced radicular pain (55). In general, the best way to treat syndrome X is to eat less and exercise more (24,105), which is a very fundamental and historically recommended practice to help promote long-term health. In recent years, the "Mediterranean diet" has become popular, which focuses on the consumption of fish, lean meats, fyuits, vegetables, nuts, whole grains, and olive oil. A 2-year trial was completed in which a Mediterranean-style diet intervention was compared to a control group on prudent diet (50% to 60% carbohydrates, 15% to 20% protein, 350 h i p i n ternal rotat ion

Assessment-Typical pai n provoked by sus tained end-range, static loading ( t he h istory is typically decisive, as sustained load ing is required for a variable period of Lime to repro duce the patient's characteristic sym ptoms). The portion of the physical exa m i nation that con firms postural pain includes the absence of sym ptoms: • • •

in neutral posit ions with ful l range of movement with repeated test movements in any direction

The only posit ive exami nation flnding would be reproduction of concordant (e.g. consistent with pain o f chief symptom) pai n with prolonged (sustained) e nd-range positioning, usually slouched sitting. Treatment-Self-care utilizing postural advice

to avoid prolonged end-range loading in the direc tion which reproduced the symptoms Outcome-I m mediate reduction in pain Dysfunction Syndrome

Assessment-Concordant pai n provoked only at end-range, usually in a single di rection of l i m i ted or restricted mobi l i ty in any direction. Treatment-Frequent end-range stretching of pai nfu l , hypothesized adaptively shortened structures performed repeatedly over weeks in order to remodel and lengthen pa i n ful shortened structures. Outcome-Short-term di scom fort with stretch ing followed by i m provement in end-range sym ptoms and mobil i ty Derangement Syndrome

Assessment-Concordant pai n produced, worsened, or peri pheralized in some end-range direc t ion(s), bu t reduced, cen tralized, and/or abol ished i n another si ngle direction of end-range motion (referred to as the patient's "direct ional preference"). This is the only syn drome with m id-range pai n . '

Chapter Thirty-Four: Integrated Approach to the Lumbar Spine

Treatment-Repeated end-range exercises ( load i ng) in direction wh ich reduces, centrali zes, and/or abolishes pain . Avoidance of repeated or static end-range l oading in the d irection found to produce, worsen , or periphera l i ze sYl?ptoms. Outcome-Centralization of referred symptoms and e l i m ination of local symptoms. Restoration of normal mobi l i ty. Active Limb Movement Testing Classification

Shirley Sahrmann has proposed a testing system based on specific movement i mpairments related to provocation of the patien ts' typical pain (Figs. 34.8 to 34. 1 3 ) . Posi tive test findings have been s hown to be related to pai n i n tensity and functi onal disab i lity i n a group or patients w i t h LBP or sciatica more t h an 7 weeks ( n 18 8 ) (66) . The tests used have been shown to be reliable (64 ) . Pre l i m inary evidence sug gests that classification based on this assessment can be valuable for gui d i ng t reatment decisions i n L B P patients (4 1 ,66). =

Canadian Back Institute Classification Approach

The Canadian Back Institute demonstrated the relia bility of a pain pattern system utilizing key elements from the h istory and examination (73). They demon strated 78.9% agreement amongst examiners u t ilizing their approach. Furthermore, u n like the successful McKenzie study mentioned, only m i ni mal tra i n i ng was required. This approach is only i n the preli m i n ary stages of validation.

A Functional Screen It is frequently d i fficul t to pinpoint the specific pain generating t issue responsible for LBP syndromes. Even in cases where a tissue-speci fi c diagnosi s i s attained , t he reasons beh i nd i ts generation are often elusive. For these reasons, and to guide the rehabi l i tation effort, a th orough functional evaluation i s needed. In fact, various fun c t ional deficits ( i m pair ments) have been shown to correlate w i t h LBP (see Chap ters] and 5 ) . An adequate diagnosis for LBP patients must i nclude both t issue-specific and func tional elements. Functional defici ts may be categorized as quanti tative or qual i tative. Quanti fiable fun c tional tests h ave been covered in detail in C hapter 1 1 . This sec t ion will provide an atlas of both quan t i tative and qualitative test of motor con trol . Deficits in strength , balance, coordination, and endurance represent the spectrum of motor con trol, which when l acking can place undue mechan ical stress on pai n-sensi tive tis-

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803

sues, or lead t o b iomechanically u n favorable com pensatory motor stra tegies. The Lower Crossed Syndrome and the Spine

Janda emphas i zed the importance of m uscle bala nce i n function. The relationships between agoni sts, antagonists and synergists can be looked at i n terms of coord i nation or t i mi ng. Deficits in mob i l i ty of joints near or remote from the l umbar spine can i mpact function. Pelvic, h i p , knee, and foot/ankle joints s hould be evaluated for t hese deficiencies. For instance, poor h i p mobil i ty w i l l cause a compen satory reacti o n i n the spine. Subtalar hyperprona tion is another example o f a lower quarter functional defici t which can l ead to compensatory movements t hroughout the k i netic chain . Observation of fLlI1c tiona l activi ties, ei ther in i solated motions, or m ore complex weight-bearing [·unctions can show t h ese d i fferent motor control strategies at work, lead ing to a better u n derstanding of i ndividual patient fLlI1ction and a custo m i zed rehabili ta tion prescription. A classic example of muscle i mbalance is t he lower crossed syndrome ( Fig. 34.14 ) . This is a typi cal pos tural overstress res u l t i n g from m uscle i m balance (Table 3 4 . 6 ) . The overactive/shortened m uscles i nclude the gastro-soleus, h i p flexors, hamstri ngs, adductors, TFL, and p i ri form i s . The u nderact ive/ i nh i bi ted m uscles i nc lude the g l u t eus maximus, gluteus medi us, quadratus plan tae, peronei, and abdominal wall muscles. The erector spinae is often tight, but also loses endurance. Agon ist-antagonist synergist muscle i m balances are predictable. For i nstance, an a nkle sprain will lead to inhibi tion of the gluteus max i m us that will persist even after the ankle h as healed ( 8 ) . A k e y concept for s p i n e stability i s load sharing. The hip joi n ts are designed to handle high loads. The deep acetabulum and large surrounding musculature are capable of supporting these forces. However, if hip joint mobility i s compromised, loads may transfer to t he next available motion segment, typically the lum bar spine. I t has been shown that decreased passive h i p extensi o n mobility is related to L B P (36,44,65 ) , as is decreased h ip i n ternal rotation ( 1 2,2]) . Prel imi nary data from McGill suggest t hat decreased hip extension m ob i l i ty may be predi c tive of disabling LBP (44). Van D illon reported that chronic LBP subjects had l ess passive h ip extension mob i l i ty than asymptomatic subjects (65 ) . Studies in adolescents have documented that future episodes of L B P are correlated with decreased hip extension R O M (36). N adler et a1. demonstrated that hip muscle imbal ance is associa ted b o t h retrospec tively and pro spec tively w i t h LBP in female athletes (48, 49). In particular, asymmetric h i p extensor strengt h was sig n i ficantly correlated with LBP i ncidence. Those wi th

804

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Part Six: Practical Application by Region

Figure 34.8A, B Knee extension in

Figure 34.9A, B H i p abduction and

Figure 34. 1 0A, B Knee nexion in

s i l t ing.

lateral rotation in partial hook-lying.

prone.

Figure 34. 1 1 A, B H i p rotation

Figure 34. 1 2A, B H i p extension .

Figure 34. 1 3A, B Quadruped arm

prone.

prone.

reach .


, I I I ,

Erector Spinae

�

,

Abdominals

I I

Iliopsoas

Gluteus Maximus

Tight

Weak 0< Inhibited

Weak or Inhibited

Tight

Figure 34. 1 4 Lower crossed syndrome.

LBP had a 15% strength i mbalance compared w i th only a 5 . 3% imbalance in those without LBP. This same asymmetry was not found i n male athletes, but it is in teresting to note that National Col legiate Ath letic Associat ion Injury Surveil lance Data from 1997 to 1998 showed t hat female athletes were almost twice as l i kely as males to develop LBP ( National Col legiate 1 997-1998). Other consistent fi ndi ngs i nc lude increased fatigabi l i ty of the glu teus m aximus in indi viduals with chronic LBP (32,38). Vogt et al . found that reduced act ive hip extension (Janda's test) range of motion ( R O M) and delayed relaxation of t he glu teus maximus and lumbar erector spinae muscles can dist i nguish back pai n subjects from asymptomatic individuals (68,69). Simi larly, delayed relaxation of trunk agonist and an tagonist muscles duri ng func-

Table 34.6

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805

t ional tasks has been shown to disti nguish LBP indi viduals from asymptomatic people ( 1 1 ,5 5 ,56). A positive active straight leg raise (hip flexion) has been shown to be assoc iated w i t h postpartu m sacro il iac (SI) pain (46). Sensi tivity was 0.87 and specifici ty was 0.94 (45 ) . It has been s hown that al tered k i ne matics of the diaphragm and pelvic floor are present in those with a positive test (51). A key factor in t h e lower quarter kinetic chain is gluteus m ed i us weakness (54). Mascal et a l . have demonstrated t hat a pelvic drop and excessive knee valgus duri ng a step down task i s i n d icative of con tralateral gluteus medius weakness (42). Ireland et a l . h a s showed t h i s weakness i s com mon i n patients with knee pai n ( 3 1 ) . Speci fically, defic i ts o f 2 6% in h i p abduction strength and 3 6% h i p ex ternal rota tion strength were found. Hewett et a l . have shown in female collegiate athletes that supi natory trai n i ng during plyometric squats prospectively reduced the incidence of injury i n the com i ng season (28). Gait abnormalities have been found to be associ ated with LBP. Arendt-Nielson found both over- and under-activity in muscles duri ng di fferent phases of gait i n chronic LBP subjects, but not in asymptomatic subjects ( 3 ) . Overactivity of back muscles was found during the swing p hase of gai t and decreased agon ist peak muscle activity duri ng the double stance phase was found in L B P patients ( 3 ) . H ussein has reported t hat stride length is decreased in the gai t of LBP i ndi viduals compared to normals (29,30). Lamoth and col leagues recently found that pelvis-thorax coordination in the LBP group differed significantly [Tom that in the control group ( 3 7 ) . Specifical ly, they reported that a more rigid, less flexible pelvis-thorax coordination, and slower gait velocity characterized the gai t of LBP patients versus asymptomatics. In asymptomatic indi viduals as gai t accelerates transverse plane rotation of t he pelvis and thoracic regions becomes u ncoupled because of counter-rotation . However, in LBP subjects this uncoupling did not occur. Hyperpronation of the subtalar joint has been asso ciated with t he development of many musculoskeletal conditions. The mere presence of hyperpronation does not predict LBP; however, it may add to or perpetuate existing biomechanical stresses on the system, lead ing to overload e lsewhere. Hyperpronation w i l l create lower extre m i ty i nternal rotation. If uncontrolled by

Muscle Imbalance an d Altered Movement Patterns

Weak Agonist

Overactive Antagonist

Overactive Synergist

Movement P a ttern

Gluteus maximus Gl uteus medius

Psoas, RF Adductors

Erector spi nae, hamstri ngs QL, TFL, piri formis

Hip extension Hip abduction

Table Key: RF, reclus femoris; QL, quadralus l u m borum; TFL, lensor fasci a l atae.

806


eccentric motor control, th is can lead to mechanical stresses at the knee, h ip, and lumbar spine (47). Ankle dorsiflexion of at least 1 0 degrees is also requi red for normal gai t . The typical compensation for inadequate ankle dorsiflexion is i ncreased pronation. At least 60 degrees of dors i flexion at the first meta tarsal phalangeal ( MTP) joint is requ i red for normal gai t . Less than this amount will c hange gait mechan ics; typically a reduction in s tride length and altered lower extre m i ty rotation at toe off. Hip rotation demands t he n c hange and h i p/spi n e mechanics are al tered . First MTP dors i flexion is i n hi b i ted i n the hyperpronated foot. Adequate dorsi flexi o n of the first MTP joint is also necessa ry to create suffici ent tension i n the plan tar fasc ia, which in turn creates greater medial longitu d i nal arc h stabil i ty. This process i s known as the wind lass mechanism and is essen tial for efiici e n t toe orr. Fa i l ure to attain adequate supinat ion during ter minal stance may lead to compensatory kinetic chain reac t ions contributing to not only foot/ankle prob lems, but potentially knee, h i p or low back pain syn dromes as wel l . W h e n combi ned i n closed-ch a i n fu n c t ional ac tivi ty, such as l u nges, squats, or l ihing tasks, t hese mecha n ical aberrancies can be observed t h rough out the lower extrem i ty and spine. As hyperprona tion or genu valgus are observed during s ingle-leg squatting, the evaluati o n m u s t attempt to measure how m u c h and j u dge how wel l con tro l l ed? T h i s i s t he essence o f t he quant i tative a n d quali tative eval uation o f m ove m e n t .

Atlas o f Functional Screens

The pu rpose of h.ll1ct ional assessment is to identify a patien t's f-unctional or perFormance deficits and capa bilities. The modern management of neuromusculo skeletal problems focuses on functional reactivation, restoration and rehabilitation. Structural problems such as herniated d iscs or arthritis are relevan t in just a small percentage of cases, typically t hey are coinci dental findi ngs. Therefore, the functional assessment has become a pivotal and often m isunderstood com ponent in patient care. For each test the patien t's mechanical sensi tivity ( MS) and abnormal motor con trol (AMC) is noted. This at las follows a consistent format for describing each test: •

Indicat ions

•

Procedure

•

Score

•

If pos it ive, possible treatments to consider

o o o

Tissue to relax/stretch Tissue to adjust/mobilize Tissue to faci l i tate/strengthen

Th i s functional assessmen t does not replace the i ni t i al d iagnostic triage of patients, but rather comple ments it. Evidence-based consensus panel guidelines conclude that for over 80% of back pai n the exact pai n generator cannot be identified and the label nonspecific or mechanical back pai n is applied. It i s precisely because of t h is si tuation t h a t t h e functional assessment is so i mportant. Patients want to know what is causing their pain, and while a functional diagnosis does not pinpoint causali ty it does give the clinician essential targets for funct ional reactivation as well providing simple, inexpensive tests that can be used to audit the patien t's progress towards func tional goals and recovery. Choosing the correct functional tests is an art not a science. Acute patients will receive a functional assess ment l i m i ted mostly to range of motion ( ROM) and orthopedic tests. Identifying t he movements or posi tions that reproduce the patient's characteristic pain t heir MS-is essential on an initial visit. This becomes an essent ial audit tool (e.g., post-treatment check) for adjudicati ng and legitimizi ng the treatment or exercise prescription, and thus motivating the pat ient. Once acute pai n settles a more com prehensive functional assessment evaluating AMC can also be performed (Table 34.7). The tests chosen will be based on the h.ll1 ctional goals or activity in tolerances (AI) of the patient. In other words, identify what activi ties they want or need to do that they are having di fficulty with. For i nstance if walking is an A I then assessment of bal ance, psoas length, Vleeming's SLR, hip abduction and hip extension coordination would be appropriate tests. --- ---

Functional Screening Tests for the Lumbo-Pelvic and Lower Quarter Regions

Table 34.7

1. 2. 3. 4. 5. 6. 7. 8. 9. 1 0. 1 1. 1 2. 1 3. 1 4.

Single-leg standing balance Vele's reflex stabil i ty test Squat Single-leg squat Lunge Modified Thomas test Vleeming's active & resisted SLR Janda's hip abduction test Janda's h i p extension test Side bridge endurance Trunk extensor endurance Janda's trunk flexion test Trunk flexor endurance T4 mobil i ty-arms overhead test


1. Single Leg Standing Balance Test

-

807

o

Indications •

Elderly/rail prevention

o

E i t her hand reaches for support

•

Poor balance

o

Foot is put down

•

History or ankle sprains

•

Subacute musculoskeletal pai n ( MSP)

•

•

In particular: o

Lower extrem i ty pai n

o

Low back pai n ( L B P )

•

Procedure •

•

•

I nstruction: Stand on one leg and look straight ahead ( Fig. 34. 1 5A)

•

If they can do 1 0 seconds eyes open (EO), then use this i nstruction:

•

o

•

Stand on one leg and look straight ahead, rocusing on spot on the wal l in front of you.

o

•

•

o

S ingle-leg balance (Figs. 34. 1 5 D , E )

o

Rocker board i n all three planes

o

Eyes open

•

•

o

Fai l ir: Stance root hops or twists on floor

Figure 34. 1 5A landa's varia tion, single leg balance lest.

Tiny steps w i thout sandals Su pported tiny steps w i t h sa ndals Unsupported t i ny steps with sandals Balan c ing on Bosu

•

Foot of raised l eg is at knee height and not allowed to touch stance leg

Pass if they can last 10 seconds w i t h EC on both legs (optional, test up to 30 seconds)

Static (holding still and level) ( Fig. 34. 1 5F) Dynami c ( moving) Balance sandals (Fig. 34. 1 5 G )

•

Patient gets up to five tries on each leg

o

Sensory-motor t ra i n i ng

•

Score •

Model "small foot" ( passive, active-assistance, active) (Fig. 34. 1 5 C )

Now, keep balancing and close your eyes (EC)

Janda's variation o

Janda's variation: Fail ir there is a pelvic side sh i ft of greater t h an 1 inch during the single leg stan d i ng balance test with eyes open ( Fig. 34. 1 5 B )

I f Positive, Possible Treatments to Consider

Patient chooses preferred one-leg stance position

o

N ormative data ( 5 )-20 to 49 years 24 to 2 8 seconds; 50 to 59 years 2 1 seconds; 60 to 69 years 1 0 seconds; 70 to 79 years 4 seconds

o

•

Balance reaches ( arm or leg) ( Fig. 34. ISH )

Functional trai n i n g o

Lunges ( Figs. 34 .151, J )

o

Pulleys (Fig. 34 . 1 5 K)

Figure 34. 1 58 Pelvic side s h i ft .

808

--


Figure 34. 1 5C Passive model ing of the small [oat.

Figure 34. 1 50 Single-leg balance on noor.

Figure 34. 1 5E Single-leg

Figure 34. 1 5F Rocker

balance on roam pad .

board.

Figure 34. 1 5G Walking w i t h balance sandals.


--

809

Figure 34. 1 51 Figure 34. 1 5H Balance

Forward lean and

reach (arm or leg).

step (Janda lunge).

Figure 34. 1 5J Angle l unge.

Figure 34. 1 5K Si ngle leg punch.

Part Six: Practical Application b y Region

810

2. Vele's Reflex Stability Test of the Transverse Arch

( Fig. 34. 16A) Indications •

Slrali ficalion ( Layer) syndrome

•

Acute or subacule MSP

•

In parLicular o

Lower eXlremity pain

o

LBP

If Positive, Possible Treatments to Consider •

Relax/slrelch o

•

AdjusLlmobi l i ze o

•

•

FaiJ i f delayed or absent gripping of toes

Inchworm Roll i n g towel Picking up pencil Sensory motor train i ng •

•

•

•

Intrinsic muscles of t he fool ( Fig. 34. 1 6D) •

Lean forward from the ankles w i t hout bending at the waist

Score

Fool ( Fig. 34.16C)

Fac i litale/slrenglhen o

Procedure

Cal f (Fig. 34 .16B)

o

Forward lean with toe gripping and side-to side swaying (same as Fig. 34 .16A)


--

81 1

Figure 34. 1 6C Foot adjustment.

Figure 34. 1 6A Vele's renex stabil ity test.

Figure 34. 1 60 I nchworm. Reproduced with perm is sion from Liebenson CS. Sensory-motor trai n i ng. J ournal of Bodywork and Movement Therapies. 200 1 ;5;1 :2 1 -2 5 .

Figure 34. 1 6B Cal f stretch .

812


3. Squat

( Fig. 34 . 1 7 A) Indications •

Lower quarter pain, in particular knee pain

•

Back and neck pain

•

Elderly

•

Lirting occupation

Procedure •

Stand with feet h i p width apart

•

Arms straight ahead, or supported

•

Squat down u n t i l thighs are nearly parallel to the floor (less if acute or elderly)

Score •

Fail if: o

Decrease depth of squat

o

Subtalar hyper pronation ( Fig. 34.17B)

o

Knee valgus ( Fig. 34 . 1 7B)

o

Knee flexion beyond line or toes ( Fig. 34.17C)

o

Possibly due to restricted posterior hip capsule tightness Lumbar hyperex tension

o

Lumbar flexion ( Fig. 34. 1 7 D)

•

I f Positive, Possible Treatments t o Consider •

Fac i litate/strengthen o

•

Bridges ( Fig. 34 . 17E)

Functional training o

Squats ( Figs. 34. 1 7F, G , H)

o

Lunges ( Figs. 34. 1 71, J)

Figure 34. 1 7A Squat test.

B

Figure 34. 1 78, C (B) Squat with hyperpronat i on and knee valgus. (C) Squat with knee beyond l ine of toes.

Figure 34. 1 70 Lumbar Oexion.


Figure 34. 1 7E Bridge w i t h band.

Figure 34. 1 7F Ball squat.

Figure 34. 1 7G Squat with back to wal l .

Figure 34. 1 7H

Figure 34. 1 71 Forward lean and

Squat racing wall .

step.

Figure 34. 1 7J Angle l unge.

--

813

814

--


4. Single-Leg Squat Test

0

( Fig. 34.18A) Indications •

Lower quarter pain

•

LBP


Procedure •

Stand on one leg

•

Perform a mini-squat

Score •

•

•

Fai l if: a

I nability to perform

a

Subtalar hyperpronation ( Fig. 34. 1 8B)

a

Knee valgus ( Fig. 34. 1 8B)

a

Knee flexion beyond l i ne o f toes

a

Trendelen berg sign ( Fig. 34. 1 8C)

•

Relax/stretch a

Piriformis ( Fig. 34. 1 8D)

a

TFL and IT Band ( Fig. 34. 1 8E )

a

Posterior h i p capsule release ( Fig. 34. 1 8F)

Facilitate/strengthen a

G l u teus medius ( Fig. 34. 1 8G)

a

Single-leg bridge ( Fig. 34 . 1 8H)

Sensory-mo tor balance training ( Fig. 34. 1 8I ) Functional training o

Single-leg squats ( Fig. 34. 1 8J, K)

Figure 34. 1 88, C Single-leg squat with knee valgus, s ingle-leg squat w i t h Trendelenburg sign.

Figure 34. 1 8A Si ngle leg squat test.

Figure 34. 1 80 Piri rorm is stretch.


-�

Figure 34. 1 8E I T band release w i t h foam . Figure 34. 1 8F Posterior h i p capsule mob i l i zation .

Figure 34. 1 8G Sister Kenny gluteus Figure 34. 1 8H Single-Ieg bridge.

med i u s fac i li tation.

Figure 34. 1 81 Balance

Figure 34. 1 8J Single-leg

Figure 34. 1 8K Su pported ru n n ing

reac h.

squat.

man.

815

816

--


5. Forward Lunge ( Fig. 34 . 1 9A) Indications •

Lower extrem i ty pai n

•

LBP

Procedure •

•

Step forward and kneel on the floor with one knee down The n, rise back u p to a standing position

Score •

Fail i f: o

I nabi l i ty to reach the floor with the back knee

o

Poor balance

o

Subtalar hyperpronation

o

Knee valgus

o

Knee flexion beyond l i ne of toes

o

Trunk Ilexion ( Fig. 34. 1 9B)


•

•

Relax/stretch o

H i p flexors (Fig. 34. 1 9C)

o

Anterior hip capsule (Fig. 34. 1 9 D)

Sensory-motor balance training ( Fig. 34. 1 9E) Functional trai n i ng o

Lunges (Figs. 34 . 1 9F, G, H)


Figure 34. 1 9A For

Figure 34. 1 9B

ward l unge tesl.

Forward lunge

Figure 34. 1 9C Psoas stretch.

Figure 34. 1 9E

Figure 34. 1 9F Forward lean

Figure 34. 1 9G For

Single-leg balance

and step.

ward l unge w i t h a r m s overhead.

817

Figure 34. 1 90 Anterior hip capsule mobi l i zat ion.

with trunk f lexion.

on floor.

--

Figure 34. 1 9H Angle l unge.

8 18


6. Modified Thomas Muscle Length Test (see also Chapter 1 1 )


Su bacu te M S P


Relax/st retch o

Procedure •

• •

•

Patient perc h i ng at edge of table, bring one knee to chest Slowly lower h i m or her to the table

o

•

•

Al low t he opposi te ( tested) l eg to dangle freely from the table

Femoral nerve (Fig. 34 .20D)

Fac i l i tate/strengthen o

•

An terior hip capsule ( Fig. 34.20C)

Adjust/mobili ze o

Keep knee c lose to the chest so that the back remains flat

Hip f lexors ( Fig. 34 .20B)

Bridge ( Fig. 34.20E)

Functional train ing o

Squats (Fig. 34.20F)

o

Lu nges (Fig. 34 .20G)

Score •

•

•

•

•

H the th igh is hori zontal or above hori zon tal the hip flexors are shortened or hypertonic H the knee extends beyond 90°, the rectus femoris is shortened Jf the th igh does not extend below hori zontal , but the k nee fal l s at 90°, then the i l iopsoas is shortened

r f the th igh abducts beyond neutral then the TFL is shortened If the th igh adducts beyond neutral then si ngle joi n t adduc tors are shortened

Figure 34.20A Modified Thomas tes t .

Figure 34.208 Psoas stretch.


Figure 34.20C An lerior h i p capsule mobil izal i o n .

Figure 34.20F B a l l squal.

Figure 34.200 Femoral nerve mobi l i zalion.

Figure 34.20G Forward Figure 34.20E Bridge.

l unge.

819

820

--


7. Vleeming's Active Straight Leg Raise

( Fig. 3 4 . 2 1 A ) Indications •

Subacute LBP or posterior pelvic pai n ( 4 5 , 5 3 )

Procedure •

Supi ne, have palient perform a straigh t leg raise 2 0 cm up from table

Note: Patient m ay place hands under small of back in order to palpate loss of pressure and trunk rota tion wi t h their hands. If Positive, Possible Treatments to Consider •

Relax/stretch o

Score •

•

Fai l i f: o

o

Sacroi l i ac joint pai n Sign i ncant tru n k rotation toward raised leg usual ly indicating i n h ib i ted/weak obl i que abdominals

•

Assess i f active braci ng i mproves response

•

G rade muscle strength o

Perform resisted strength test (with leg raised 2 0 c m from the table)

Adjust/mobi l i ze o

•

Bridge ( Fig. 3 4 . 2 1 D)

Stab i l i za t ion training o

•

Sacroi l i ac joint (Fig. 3 4 . 2 1 C)

Fac i l i tate/strengthen o

•

Piriform is and h i p flexors ( Fig. 34.2 1 B)

Core/tru nk ( Figs. 3 4 . 2 1 E, F, G , H)

Functional trai ning o

Squats ( Fig. 3 4 . 2 1 1 )

o

Lu nges ( Fig. 3 4 . 2 1 J )

o

Two-handed twist with cable ( Fig. 3 4 . 2 1 K)

Figure 34.2 1 A Vlee m ing's aCli ve slraight leg raise.

Figure 34.21 C Sacro i l iac adj ustmen l .

Figure 34.2 1 B Psoas P I R .

Figure 34.2 1 0 Bridge.


--

Figure 34.21 E Beginner dead bug on foam .

Figure 34.2 1 1 Ball squal.

Figure 34.21 F Dead bug wilh lwisl.

Figure 34.21 G Oblique curl-up.

Figure 34.21 H Side bridge fTom ankles wilh roll .

Figure 34.2 1 J

Figure 34.21 K Two

Forward l unge.

h anded lwisl w i l h cable.

82 J

822

--


8 .Janda's Hip Abduction Movement Pattern .


Lower extre m i ty pai n

•

Ankle sprain

•

I T Band syndrome

•

Patel lo-Cemoral pain syndrome

•

LBP

•

Gait dysfu nction such as h i p hiking

•

Quadratus l u m boru m trigger points

Score •

o

•

o

o

Side lying with lower leg flexed at h i p and knee

•

Pelvis perpend icular to the table

•

Slowly raise leg straight u p to the ceil i ng

o

•

At i n i t iation of movement, cephalad shift of pelvis indicates QL substi tution ( Fig. 34.22B)

Fail i f the first 400 occurs with: o

Procedure •

Fail i f:

Hip flexion-TFL substitu tion ( Fig. 34.22C) Hip external rotation-piriform is subst i tution Pelvic rotation-substitution pattern indicating glu teus medius weakness Reduced range of motion in abduct ion adductor tightness

Grade muscle strength o

Perform resisted strength test with leg pre posi tioned i n 2 00 to 300 of pure h i p abduction


Relax/stretch o

•

Facili tate/strengthen o

•

Figure 34.22A J anda's h i p abduct i o n test .

•

TFL, piri form is ( Fig. 34 .22D), adductors ( Fig. 34 .22E), quadratus IUl11 borul11 , IT band ( Fig. 34. 2 2 F) G lu teus medius (Figs. 34 .22G, H, I )

Sensory-motor balance training ( Figs. 34 .221, K) Functional train i ng o

G l uteus medius ( Figs. 34 . 2 2 L , M )

Figure 34.22B Cephalad s h i ft of pelvis, quad

Figure 34.22C H i p nexion, TFL subs t i tu tion

ratus l u m boru m subst i t u t ion Liebenson CS,

L i ebenson CS, Chapman S. Lumbar Spine:

Chapman S. Lu m bar Spine: Making a Rehabil

Making a Rehabil i tation Prescri ption. Lippin

i tation Prescri p t i o n . Lippinco t t W i l l iams and

cott W i l l iams and W i l k in s , 1 998.

Wilki ns, 1 998.


--

823

Figure 34.22H Si ngle-leg bridge.

Figure 34.220 Piri formis PIR.

Figure 34.221 Wall ball .

Figure 34.22E Adductor PIR.

Figure 34.22L Si ngle-leg squaL.

Figure 34.22F I T band release with foam .

Figure 34.22J Single-leg stance.

Figure 34.22G Sister Kenny gluteus

Figure 34.22K Wal k i ng with bal

Figure 34.22M

medius faci l i tation.

ance sandals.

Balance reac h .

824

--


9. Janda's Hip Extension Movement Pattern

0


•

•

Gait dysfunct ion such as lumbar hyperextension or decreased stride length .

Grade muscle strength o

Perform resisted strength test (with leg i n approx i mately 1 00 o f h i p extension)

Subacute M S P LBP

If Positive, Possible Treatments to Consider

o

Ankle sprain

•

o

Neck pai n

o

Relax/stretch o

•

H i p flexors (Fig. 34 .23D), hamstri ngs

Adjust/mobi l i ze

Procedure

o

H i p join t ( Fig. 34.23E)

•

Prone

o

Femoral nerve ( Fig. 34.23F)

•

Raise leg towards ceil i n g

o

Thoracic spine (T4-8 ) ( Fig. 34.23G)

Score •

Sensory-motor train ing (Fig. 34 .23H )

•

Faci l i tate/strengthen

Fa i l i f: o

•

•

At i n i t i ation of movement, anterior pelvic t i l t occurs

o

•

o

o

o

Lum bar hyperex tension or trunk rotation occurs (Fig. 34 .23B) Delayed activation of the gluteus maximus

Stab i l i zation training o

Fai l i f wi t h i n the first 1 00 of leg raisi ng: •

Bridges (Fig. 34. 2 3 1 ) Core/trunk ( Figs. 34 .23J , K, L, M)

Funct ional training o

Squats ( Fig. 34 .23N )

o

Lu nges (Fig. 34 .230)

Knee flexes i ndicates hamstring substitution ( Fig. 34 .23C)

Note: Patient m ay place hands u nder pelvis (AS1S) and palpate loss or pressure and t ru n k rotation with their hands.

Figure 34.23C H amstring su bst itution. Liebenson CS, Chapman S. L u m bar Spine: Making a Rehab i l i ta t ion Pre

Figure 34.23A Janda's h i p extension test.

scription. L i pp incott W i l l iams and Wilkins, 1 998.

Figure 34.238 An terior pelvic t i l t . Liebenson CS, Chap man S. L u m bar Spine: Making a Rehabil i tation Prescrip

Figure 34.230

tion. Li ppinco t t W i l l iams and W i l k i n s , 1 998.

Psoas P L R.


--

825

Figure 34.231 Bridge. Figure 34.23E H i p traction.

Figure 34.23J Quad leg reac h.

Figure 34.23F Femoral nerve mobil i zation.

Figure 34.23K Side bridge from k nees.

Figure 34.23N Ball squat.

Figure 34.23G Thoracic spine mobil i zation.

Figure 34.23L Side bridge fTom a n kl es, with rol l .

Figure 34.230 Forward lunge w i t h

Figure 34.23H Rocker board.

Figure 34.23M Begi n ner dead bug on foam .

anns overhead.

826

--


10. Side Bridge Endurance Test ( Fig. 34 . 24A) Indications •

•

LBP

Quantitative data (see Chapter 1 1 ) (43) o

o

Procedure •

Perform test on each side

•

Raise pelvis from floor until spine is aligned

•

Only feet and forearm/hand are on floor

•

Abi l ity to maintain posit i o n is t imed

Score •

Record time to fai lure o

W he n pelvis begins to lower, cue t hem to raise up aga i n . The second time pelvis drops from it's peak h eight the time is recorded as the fai l u re time.

Less t han 45 seconds is dysfu nctional A side-to-side difference i n time of greater than 5% is dysfuncti onal


•

Relax/stretch o

Hip flexors ( Fig. 34 .24B)

o

A nterior h i p ( Fig. 34.24C)

Stabil i zation train i ng o

Side bridges ( Fig. 34.24D)


Figure 34.24A Side bridge endurance test.

Figure 34.24C Anterior h i p mobi l i zation.

Figure 34.240 Side bridge from knees.

Figure 34.248 Psoas stretch.

--

827

828

--


1 1 . Trunk Extensor Endurance Test-Sorensen's Test ( Fig. 34.25A) Indications •

Subacute or chronic L B P

•

Prevention of LBP


o

•

Procedure •

•

ASIS supported at edge of treatment table or BackStrong machine Arms at sides or across chest

•

Raise u p until t ru n k is horizontal

•

Abil ity to m ain tain position is timed

Relax/stretch H i p flexors ( Fig. 34 .25B)

Facil itate/strengthen o

Tru n k extensors ( Figs. 34 .25C, D, E)

o

G l u teus m aximus ( Fig. 34 . 2 5 F)

o

Hamstri ngs ( Fig. 34 . 2 5 G )

Score •

Record time to fai l u re o

•

When tru n k begins to lower, cue them to raise up again. The second time back drops from i ts peak height the time is recorded as the fa ilure time.

Quanti tative Data (see Chapter 1 1 ) o

o

Less than 60 seconds is dysfunctional (2,43) A back extensor endurance t i me t hat is less than a trunk flexor endurance time or side bridge endurance ti mes is dysfunctional (43)

Figure 34.258 Psoas stretch .

Figure 34.25A T m n k extenso)" endu rance tes t .


Figure 34.25C Quadruped opposi te arm and leg reach.

Figure 34.25F Bridge.

Figure 34.250 Superman on bal l .

Figure 34.25G Hamstring curl .

Figure 34.25E Back strong, beg i nner.

829

830

--


1 2. Trunk Flexion Coordination Test


Subacute or chronic LBP


Relax/stretch o

Procedure • •

•

•

Supine with knees slightly flexed Perform curl-up u n t i l scapulae are off the tablelfloor Al ternative test: o

Stabil i zation training o

•

H i p flexors ( Fig. 34.26C) Core/tnmk (Figs. 34 .26D-H)

Functional train i ng o

Core/trunk ( Figs. 34.26 I-K)

Cup heels and ask subject to exert downward pressure w i t h heels and then perform curl-up

Score •

Fail i f: o

o

Feet rise up from table before scapulae come off the table (maj or dysfunction) ( Fig. 34.26B) Downward pressure l ost prior to scapulae l i fting completely up ( minor dys["u nctio n )

Note: Hyperlordotic patients may have a false posi tive since it takes much more effort to curl-up

Figure 34.268 Feet rise up fTom table before scapulae come completely o ff, Liebenson CS, C hapman S. L um bar Spi ne: Making a Rehabil i tation Prescription. Lippincott Will iams and W i l k i ns, 1 998.

Figure 34.26A Tru n k flexion test.

Figure 34.26C Psoas stretch.


--

83 1

Figure 34.26H

Figure 34.260 Basic curl-up.

Side bridge from an kles, w i t h rol l .

Figure 34.26E Begi n ner dead bug o n foam .

Figure 34.261, J Wood chops.

Figure 34.26F Dead bug w i t h twist.

Figure 34.26K Two Figure 34.26G Side bridge from knees.

handed twist w i t h cable.

832

--


1 3. Trunk Flexor Endurance

( Fig. 34.26L) Indications •

Subacute or chronic L B P

Score •

Procedure • • •

•

Record time to failure (when t runk leans back into wedge) o

Leaning supported on 50° wedge Feet anchored by tester Wedge i s pushed back 4 i nches, patient must maintain spinal alignment

°

•

•

Less than 50 seconds is dysfunctional (43)

Quanti tative Data (see Chapter 1 1) °

Abil ity to maintain position i s t imed

Patient is given cues if posi t ion is lost, mul t iple cues can be given until failure occu rs

Less than 50 seconds is dysfunctional (43)

Trunk flexor endurance li me should be longer than the side bridge endurance lime, but weaker than the trunk extensor endurance time


Figu re 34.26L Tru n k flexor endurance test.

(similar treatments as previous test)


1 4. T4 Mobility Screen-Arm Overhead Test (50) (Fig. 34.27 A) Score

Indications •

Subacule or chronic M S P

•

Poor poslure

•

Osteoporosis

•

Fail i f: o

o

Procedure •

•

o

Sland with back agai nst a wall and feet slighlly forward

Lumbopelvic junction hyperextends ( Fig. 34.27B) Arms don't reach vertical plane (Fig. 3 4 . 2 7 B ) Thoracic kyphosis remains

I n strucl patient to raise their arms overhead

A

B

Figure 34.27A, B Arm overhead test. L u mbar hyperextension and reduced glenohumeral range of motion.

--

833

834

--



•

•

Relax/slretch o

Latissimus dors i , pectoralis major/m inor

o

Brea t h i ng exercises

Adjusl/m ob i l i ze o

Stabilization lra i n i ng o

•

Core/tru n k ( Figs. 34.27E, F, G )

Func lional trai n i ng o

Backhand ( Figs. 34 . 2 7 H , 1 )

o

Overhead cable pull down ( Fig. 34.27J )

Thoracic spine (T4-8) ( Figs. 3 4 . 2 7 C , D)

Figure 34.27C Upper back c a t on bal l .

Figure 34.27E Dead bug on roam w i t h medicine ball overhead.

Figure 34.27F Crunch s tart posi t ion w i t h ribs elevated, i n halation position. D

Figure 34.270 Wall slide.


--

Figure 34.27G Crunch start pos i t i o n with r i b s depressed, exhalation position.

Figure 34.27H Angle lu nge

Figure 34.271 Angle l unge

Figure 34.27J Overhead cable pu l l

backhand, start pos i t ion.

backhand.

dow n .

835

836

--


Cases This section details a few examples of common clini cal presentations. A common format i ncorporating the di fferen t key elements o f care in a repeatable prac tice model will be shown (34). Kibler's functional kinetic chain model is presented for each case to show how management should not be limited to merely an orthopedic assessmen t of the pain generator, but should be predicated on a functional assessment (Tables 3 2 . 7 and 3 2 . 8 ) . Additionally, the goals of care will be presented for each case (palliative, tissue sparing, ti ssue-stabilizing, and functional tra i n i ng) (Table 32 . 1 1 ). Within the goals of care are subsumed the con tinuum or steps of care (advice, manipulation, and exercise) (Table 32 .9). For example, sparing strate gies i nclude advice on ergonomic modifications or manipulations of joints or soft tissues; and exercise is included in bot h stabi lizing and functional train ing.

Clinical Pearl

The Prague school or manual med icine ( Lewit & Janda) espoused the general rule that t ight m uscles should be relaxed PRIOR t o a strengthening program being i n iti ated. The pUl-pose being to avoid unwanted substitution patterns occurri ng during strength t raining with syner gists compensating ror agonists. This is consistent with s tabi l i zation t ra i ni ng approaches of Waterloo, Canada ( McG i l l ) and Queensland, Austra l i a ( Richardon, Jul l , Hodges). The Waterloo approach recommends that lower quarter mobi l i ty deficits are addressed to ensure load sharing of t h e spine during stabi l i ty training. The Queens land approach emphasizes the importance or addressing "global" muscle overactivi ty duri ng "local" stabil i zation training to avoid synergist substitu tion.


--

837

Case 1 : Herniated Disc Kinetic Chain Approach

Goals o f and Continuum o f Care

Clinical symptom complex: Nerve root symptoms below the knee worse with sitti ng, flexion and in the morn i ng ( Fig. 34.28A)

Palliative care: reduce i rritabi l i ty of nerve root

Tissue injury complex: Nerve root compression or tension due to disc herniation ( Fig. 34.28B)

Sparing Strategies:

(McKenzie, trac t i o n , modali ties) (Figs. 3 4 . 2 8 E , F, G ) •

Sou rce o(biomechanical overload: End range

loading of disc during ADLs ( i . e . , sitti ng, l i fting, and forward bendi ng) ( Fig. 34.28C). Pertinent Factors include: •

•

•

•

Temporal-pain in morning or after prolonged flexion ( i . e . , sitting and stooping) Poor physical fitness and respiratory challenge leading to loss of abdominal stabilization of low back Coupled flexion and rotation; reduced mobi l i ty of peripheral joints of the lower extremity and compensatory hypermobility of lumbar spine in flexion Reduced coordination or endurance of spinal stabilizers (deep spinal extensor m uscles, QL, deep abdom inal stabi l i zer m uscles)

Dysfunctional kinetic chain: •

• • •

Inadequate lumbar segmental stabi l i ty in the sagi ttal plane with flexion overload during bending and l i ft i ng activities due to back extensor fatigue (e.g. , m u l t ifidus). Poor lateral stability caused by Q L fatigue Fon-vard lunge with trunk flexion Squat with trunk flexion ( Fig. 3 4 . 2 8 D )

•

• •

Activity modification advice ( postural awareness training) ( Fig. 3 4 . 2 8 H ) Mobil i ze l ower extremi ty peri pheral join ts and T4-8 Release gastro-soleus, hamstring, h i p flexors Consider neuromobil i zation of the sciatic nerve ( Fig. 3 4 . 2 8 1 ) Thi s should be performed as a slider not a tensor.

o

Stabilizing Strategies: •

Fac i l i tate back extensors and side support muscles ( Fig. 34.28J , K)

Functional Training: •

Reeducate postural awareness of neutral spine during l i fting, bending, and s i t t i ng. ( Fig. 34.28L)

838

--


Figure 34.28A Referred pai n from an i rritated or A

compressed S- l nerve root.

Figure 34.280 Squat w i t h t r u n k nexion.

Figure 34.288 Nerve root compression caused by disc hern iation.

Figure 34.28E M cKenzie prone extension exercise.

I

� Figure 34.28F M anual traction

Figure 34.28C End range load ing of d i sc dur i ng A D Ls .

F

of the pelvis.


Figure 34.28J Quadruped arm and leg reach .

Figure 34.28G Sup i ne rhy t h m i c trac t ion of the l u m bar s p i ne.

G

Figure 34.28K S i d e bridge.

Figure 34.28H Hip h inge.

Figure 34.281 Sci atic nerve s l ider neuromobi l i zalion.

Figure 34.28L B a l l squat.

--

83 9

840

--


Case 2 : Facet Syndrome Kinetic Chain Approach

c.

Clinical symptom complex: Low back pai n

( Fig. 34.2 9A )

Inadaquate l umbar segmental s lability in the sagital plane with exlension overload during l i fting activit ies.

Tissue injury complex: Facet syndrome ( Fig.

Goals of and Continuum of Care

34.29B)

Palliative:

Source of biomechanical overload: End range

•

Reduce irritability of facet joinls (adj ustments, modal ities, sofl lissue manipulation) ( Figs. 34.29F, G , H, I)

loading of facets during A DL's (i.e., gait, reach ing overhead, etc.) due to altered axis of h i p extension or t horaci c extension w i t h prim ary ful crum in low back. Facet overstrain is also com mon if the deep abdom i nals don't stabili ze the spine in a "neutral range" during ADLs such as l i fting or exercises such as s it-ups ( Fig. 34.29C).

Spa ring:

Dysfunctional kinetic cha in:

Stabilizing

a. Reduced hip extension mobility ( D i fferential

diagnosis ( D Dx)-anterior hip joint capsule, h i p flexor muscle tightness, femoral nerve ten sion) with compensatory lumbo-sacral hyper mob i l ity in extension ( Fig. 34.29D) h. Reduced t horacic (T4-8) extension mobility

during lrunk straightening or arm flexion (Fig. 34.29E) ( D Dx-muscle tightness: pectoral, lat, subscapularis; brach ial plexus tension; and joint mobil i ty restrictions: upper thoracic extension or anterior rib depression)

•

• • •

Activi ty modification advice ( poslural awareness train i ng) ( Fig. 34.29J )

Bridge ( Fig. 34. 29K) Basic curl-up ( Fig. 34. 29L) Crunch with ball overhead ( Fig. 34.29M)

Functional • •

Wall slide ( Fig. 34.29N) Overhead pull down with cable (Fig. 34.290)


Figure 34.29A Referred pain from l u m bar spine joints.

--

84 J

Figure 34.29B Lumbar vertebral and facet joints.

C

Figure 34.29C Facet over strain wi th exercise.

E

Figure 34.290 Faulty h i p extension.

Figure 34.29E Reduced thoracic (T4) extension m ob i l i ty during arm flexion.

842

--


Figure 34.29F Lu mbar spine extension PIR mob i l i zation.

Figure 34.29G Lumbar l ateral nexion manipulation.

H

Figure 34.29H Prone rhyt h m i c traction

Figure 34.291 Lew i t fascial release.

o f t he l u m bar spine.

Figure 34.29J T4 mob i l i zation with foam rol l .

Figure 34.29K Bridge.


Figure 34.29L Basic curl-up.

Figure 34.29M Crunch wilh ball over head.

N

Figure 34.29N Wall s lide. Figure 34.290 Overhead p u l l down w i t h cable.

--

843

844

--


Case 3 : Spinal Stenosis Kinetic Chain Approach

Sparing Strategies:

Clinical symptom complex: Nerve root symptoms

•

below the knee worse w i t h standing, and walking and i n the elderly ( Fi gs. 34. 30A and B )

•

Tissue inju ry complex: Nerve root compression or

tension due to spinal stenosis ( narrowing of the spi nal canal caused by degenerative j o i n t d is ease) ( Fig. 34.30C)

•

Activi ty modification advice (postural awareness train i ng) ( Fig. 34.30E) M obilize lower extremity peripheral joints, T4-8, and lumbar spine i n flexion Release gastro-soleus, hamstring, hip flexors ( Fig. 34.30F) I f necessary release the relevant nerve, sciatic or femoral (Fig. 34.30G) o

Source o f biomechanical overload: Sim ilar to

facet syndrome

Stabilizing Strategies:

Dysfu nctional kinetic chain: Sim ilar to facet

•

syndrome

Similar to facet syndrome

Functional Training:


•

Similar to facet syndrome

Pallia tive care: Reduce i rritab i l i ty of nerve root

( Fig. 34. 30D)

A

B

NORMAL CANAL

CONG E N ITAL

DEG E N E RATIVE

CONGEN ITAL AND DEGENE RATIVE

DEG E N E RATIVE PLUS DISC H E R N IATION C

Figure 34.30A Referred

Figure 34.308 Refen-ed pain from

Figure 34.30C Normal spinal canal and various

pain from an i rri tated or

an ilTitated or compressed LS nerve

combinations o f cond i tions that may cause spi nal

com pressed S I nerve roo l .

pai n. Reproduced with perm ission

stenosis ( narrowing o f the spinal canal due to DJ D ) .

from Cox J M , Low Back Pai n :

Reprinted w i t h permi ssion fTom White A A , Panjabi

Mechanism, D i agnosis a n d Treat

M M . C l i n ical Biomechanics of the Spine, 2nd ed.

ment, 6th edition, Bal t i m ore: Lip

Philadelp h i a : J B L i p p i ncot t , 1 990:403. Obtai ned

p i ncott W i l li am s & Wilkins, 1 999;

from fig 6 . 1 7 , p 403.

obtained from fig 1 0.74, p 4 1 9.


--

o

Figure 34.300 Isometric manual traction

Figure 34.30F Psoas PIR.

of the pelvis.

E

Figure 34.30E Use of [ootstool to reduce low

Figure 34.30G Femoral nerve s l i der neuro

back strai n .

mobil i zation.

845

846

--


Case 4 : Sacroiliac Syndrome Kinetic Chain Approach

Tissue sparing: Activity modification advice,

Clinical symptom complex: Sacro-i liac (SI) pain

( Fig. 34.3 1 A)

adductor, piriformis (Fig. 34.3 1 F), IT band releases

Tissue injury complex: Sacro-iliac joint

Stabilizing:

Source ofbiomechanical overload: Sacro-iliac

•

i ns tability during ADLs (i.e. , gait, climbing stairs, forward bending, etc. )

o

Dysfu nctional kinetic chain: Poor pelvic s tabil i ty

i n stance phase of gait ( Fig. 34.3 1 B) (weak glu teus medius & overactive TFL, QL, adductors, piri form is) w i t h resultan t lumbo-sacral and SI hypermobility

o o

Functional: •


Pallia tive care: Reduce irritabil i ty of SI joint-SI

mobilizations ( Figs. 34. 3 1 C, D, E )

Facilitate gluteus medius Sister Kenny gluteus medius faci l i tation (Fig. 34.3 1 G) Si ngle-leg bridge ( Fig. 34.3 1 H ) Wall ball ( Fig. 34.3 1 1 ) Balance reach ( Fig. 34.3 1 J)

o

•

R u n n i ng man (Fig. 34.3 1 K) Single-leg pull down with cable ( Fig. 34.3 1 L)


o

Figure 34.3 1 A Sacro-il iac joint pain referral pattern. Obtained fyom SIJ referral pattern fig 1 , P 1 484 Fortin

--

Figure 34.3 1 D M o b i l i zation of t he sacro i l iac joint.

J D , April ! CN, Ponthieux B, Pier J. Sacro i l iac Joint: Pain Referral Maps Upon Applying a New I njection/ Arthrography Technique, Part I I : Clin ical Evaluation, Spine 1 994; 1 9: 1 483- 1 489.

Figure 34.31 E Mobilization o f the lower part of the sacroiliac joint.

Figure 34.31 8 Trendelenberg sign.

Figure 34.3 1 C Sacro i l iac joint manipulation .

--

Figure 34.31 F Piriformi s stretch.

847

848


Figure 34.31 G Si sler Ken ny g l u leus med i u s rac i l i l a l i o n .

Figure 34.3 1 J Balance reach .

Figure 34.3 1 H Si ngle-leg bridge. Figure 34.31 K R u n n i ng man.

Figure 34.31 L Si ngle leg p u l l down wilh

Figure 34.3 1 1 Wall ball .

cable.

Chapter Thirty-Four: Integrated Approach to the Lumbar Spine �� 849

Audit Process


How are the d ifferent U n i versity of Pittsburgh l o w back p a i n subclassifications determ i ned�

•

What rehabilitation methods should be c:onsidered for dysfunctional hip extension or abducti o n ?

•

What rehab i l itation methods should be considered

•

for a dysfunctional Vleeming's test? " What is the cont inuum of care for nerve root syndromes

•

What is t he cont i n u u m of care for facet and sacro i liac problems?

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85 1

6 6 . Van D il len L R , Sahr m a n n SA, N orton B J , M c D o n n e l l M K, F l e mi n g DA, Cal d wel l C A , Wool sey N B : The effect of act i ve l i m b move m e n ts on symptoms i n patients w i t h low back pai n . J o u rn a l of Orthopedic a n d Sports P h y s i c a l Therapy 200 1 ; 3 1 :402-4 1 3 . 6 7 . Victorian WorkCover Authority. h tt p://www. wo rkcover. vi c. gov .au/d ir090/vwa/h 0 m e. n s f/pages/ chiropractors. Accessed June 8 , 2005 . 68. Vogt L, B a nzer W. Dynamic testing of the motorial stereotype i n prone hip extension from the neutral pos i t i o n . C l i nical B iomechanics 1 997; 1 2 : 1 22- 1 27 . 6 9 . Vogt L, P feifel- K , Banzer W. Neurom uscular cont rol of walk i ng with chronic low-back pai n . Man ual Therapy 2003 ; 8 : 2 1 -2 8 . 7 0 . V o n Korff M , Ormel J , Keefe FJ , Dworkin SF, Grading the severity of chronic pa i n . Pain 1 992;50: 1 33- 1 49. 7 1 . Werneke M, Hart D L , Cook D . A descri p t i ve study of the cent ral i za t i o n phenomenon. A prospective analy s i s . Spin e 1 999;24:676-683 . 7 2 . Werneke M , H art D L . Centra l i zation phenomenon as a prognostic factor for chronic low back pa in and d isabil ity. Spine 200 1 ;26:7 5 8-765. 7 3 . W i l s o n L , Hall H , M c In tosh G , Mel les T. I n tertester rel i ab i li t y of a low back pain c1assi hcation system. Spine 1 999;24:248-254. 74. World Heal t h Orga n i zation. I n ternational Classihca t i o n of Human Functioni ng, D isabil ity and Health: I CF. Geneva: WHO, 200 1 .

Integrated Approach to the Cervical Spine

Craig Liebenson, Clayton Skaggs, Scott Fonda, and Sylvia Deily

Introduction Diagnostic Triage Red Flags Differential Diagnosis

The Functional Model The Biopsychosocial (BPS) Approach Course and Prognosis

4. Arm Abduction-Scapulo Humeral Rhythm

s. Janda's Neck Flexion Coordination Test 6. Cervico-Cranial Flexion 7. Mouth opening (Orofacial Coordination) Cases Case 1:

Limitations of Structural Pathology

Neck Pain and Non-Migrainous Headache

Impairments Associated with Pain and Disability

Case 2: Temporomandibular Joint Syndrome

Effectiveness of Reactivation

Case 3: Cervical Discogenic Radiculopathy

Outcomes

A Functional Screen

�==:::!.

Learning Objectives

The Upper Crossed Syndrome and the Spine


The Upper Crossed Syndrome and the

understand:

Orofacial Region Atlas of Functional Screens

1. Respiration Assessment

• •

2. T4-S Mobility Screen-Wall Angel 3. Push-Up Test

852

The different rehabilitation methods to consider when a specific functional test is positive

Test A-Seated Test B-Supine

How to evaluate hmctional stability

•

The continuum of care for the most common clinical symptom or tissue injury complexes

Chapter Thirty-Five: Integrated Approach to the Cervical Spine

Introduction

Table 35.1

Head, neck, upper back and referred arm pain are common problems. They are usually self-limiting,

•

--

General Red Flags fl-om the History

Age < 1 8 without precipitating event or onset age >45

but recurrent. Patients who seek professional health

Prior history of cancer

care usually have severe pain, are getti'ng worse, or

•

are simply not getting better in a reasonable time.

•

Significant trauma onset

•

Constitutional symptoms: fever, chills, night

These patients require a diagnostic triage to rule

sweats, nausea, vomiting, fatigue, diarrhea

out "red flags" of serious disease. While necessary, this is not sufficient to properly manage the case. Other steps that are essential for the promotion of a self-management approach are identification of the

•

Night pain

•

Pain unrelieved by rest or position

•

Pain or pattern of symptoms disproportionate to typical musculoskeletal disorders

patient's activity intolerances, functional deficits,

Unexplained weight loss

work status, and "yellow flags" indicative of a poor

•

prognosis.

•

Bowel or bladder habit change

This chapter will integrate together the f-unctional

•

Systemic illness (e.g. diabetes)

assessment and treatment methods necessary for pro

•

Diagnostic Triage

Red Flags The term 'Red Flags' was coined and popularized by the AHCPR Guidelines in 1 994 (5). Diagnostic triage refers to the process of evaluating and determining initial management strategies for presenting com plaints. In first contact provider situations, emphasis is placed on securing a diagnosis and implement ing the most conservative and reasonable treatment options. The likelihood of encountering sinister causes for cervical spine pain complaints is low, but always present.Most epidemiological studies noting the like lihood of encounteling a sinister or non-benign cause have focused on low back pain instead of cervical spine complaints, primarily due to the higher incidence of low back pain in the general population. In this sec tion, general red flags will be outlined, followed by

Immunosuppressed states (corticosteroid use, HIV, etc . .. )

moting self-management of activity limiting cervico thoracic complaints.

•

Failure of conservative management

neoplasm (malignancy ) , infection, visceral referral, myelopathy, and radiculopathy ( 3 0 ) . Once the gen eral index of suspicion is raised, additional lines of questioning, physical examination procedures, and diagnostic testing can be administered with greater specificity toward a single category.

Fracture/Dislocation

The presentation of fracture or dislocation is rather straight forward, but a caveat to keep in mind is that in order to cause fracture, one must sustain major trauma if healthy, however, even minor trauma in an at risk individual may be sufficient for fracture. At risk individuals may include the elderly or others with osteoporosis. Major risk factors for osteoporosis in clude ( 1 3 , 1 8 , 75,8 1 ) .

brief sections on special considerations for the cervico thoracic region and some specific conditions (see also

•

Chapter 7).

Female with: o

It is the intention o f red flags to act a s screening

o

procedures which would prompt the clinician toward

o

f-urther investigation. The majority of red flags are

Age over 55 years Low weight (< 1 2 7 Ibs.) Post-menopausal NOT taking ERT (estrogen replacement therapy)

points noted during the history taking process, thus

o

Asian or Caucasian

making thorough history taking of great importance

o

Smokers

in raising the clinician's index of suspicion to any

853

•

Males with hypogonadism

potential sinister causes for the presenting complaints (see Table 35. 1 ) . Intraspinal/Intracranial Considerations

Differential Diagnosis

Stroke and vertebro-basilar syndromes often pre sent as headache and dizziness, similar to upper cer

The conditions which red flags and diagnostic triage

vical spine mediated

are most focused upon can be divided into etiologi

hypertension or current elevated blood pressure is a

cal categories. These include fTacture/dislocation,

red flag for ischemic stroke. Although often clini-

complaints. A history of

854

--


cally silent, vertigo, visual disturbances and head

sion of neurologic deficit despite conservative man

ache are clinical manifestations of vertebra-basilar

agement warrants additional consideration. Initial

insufflciency. A presentation of headache with fever

examination must include upper and lower extremity

and cervico-thoracic complaints must be considered

muscle stretch reflexes, dermatomal light touch and

for meningitis.

sharp sensibility, and motor strength. Atrophy should be measured if possible and fasciculation should be

Neoplasm (Malignancy)

The most typical red flags alerting the clinician to the possibility of malignancy include age >50, prior his tory of cancer, unexplained weight loss, no relief with

noted if present. This will not only define the extent of the radiculopathy, but also serve as a baseline for interval compatison. Advanced imaging and/or electro diagnostic studies are the most useful diagnostic modalities for further evaluation.

rest, and failure of conservative therapy. Metastatic disease can present in any number of ways and is the most common neoplastic consideration. Other

Visceral Referral

considerations include primary benign bone tumors

One of the signs not previously listed is the failure

(osteochondroma, osteoblastoma, aneurismal bone cyst , hemangioma, and osteoid osteoma). Other

to reproduce the presenting complaints. Various

neoplastic considerations include extra- and intra

visceral conditions can create referred pain to the neck

medullary spinal cord tumors.

and cervkal region, upper thoracic region, scapular

of neuromusculoskeletal examination procedures

area, and perhaps the upper extremity ( 2 7 ) . Some of Infection

the more common origins and their referral patterns are listed below (see Table 35.2).

Infectious processes which can affect the cervical region include osteomyelitis, discitis, meningitis and perivertebral abscess formations. The index of suspicion should be particularly high in the immunosuppressed (HIV +, chronic corticosteroid use , or other immunosuppressive therapy). Other higher risk [actors include: co-existing urinary tract

Summary

There are numerous conditions which can cause neck or mid back pain. Tables 35.3 and 35.4 review the most common of these.

infection (UT I ) , IV drug use, recent surgical or inva sive procedures (including dental procedures), or a known penetrating wound (abscess). Diabetics are also known to have a higher incidence of infection.

The Functional Model

The Biopsychosocial (BPS) Approach The natural history of neck pain is poorly understood,

Myelopathy

The presence of signs of myelopathy demands delin eation of the cause and extent of the neurologic deficit. Historical detail regarding impotence and bowel or bladder continence is extremely important. Examination should include a thorough upper and lower extremity neurological examination, to include notation of motor coordination and signs of spastic ity. Causes can include instability, vertebral degen erative changes, disc herniation, or other space occupying lesions o[ the spinal canal (benign or malig nant). Trauma may play a rale in the development of myelopathy, particularly if congenital stenosis exists, or there are other risks of instability (i.e. rheumatoid arthritis).

and amazingly very little research about its causes or treatments has been performed (9,73). The severity of symptoms and the severity of trauma are not always directly related. Very few objective findings are cor related with the symptoms reported in the head, neck, or upper quarter. In a survey o[ over 1 0 ,000 cases of Whiplash Associated Disorders (WA D) pain it per sisted in 25% of the cases [or 5 years after the acci dent (20). The B P S approach recognizes the importance of reassurance and reactivation for promoting a quick recovery and minimizing the risk o[ chronicity (65,

73 ,95). A helph.tl tool for c1assi Fying neck related disorders emerged h-om the Quebec WAD Guidelines (see Table

35.5) ( 8 7 ) . It does not hypothesize about the specific cause of pain, but enables different researchers to

Radiculopathy

The presence of radiculopathy is not an immediate cause [or surgical refenal, but persistence or progres-

compare similar groups of patients. It has been pointed out that a common category like WAD II should be considered to include a heterogeneous group of patients ( 8 8 ) .


--

855

Table 35.2

Sources and Features of Visceral Referred Pain

Origin

Conditions

Historical Features

Referred Pain Region

Cardiac

Angina, myocardial

Chest pain, and risk factors (hyper-

Chest, left shoulder/medial

infarction, pericarditis

pension ( HT N ) , Coronary artery

arm, anterior neck

disease (CAD ) , hyperlipidemia, smoking) Pulmonary

Pleurisy, pulmonary

SOB/dyspnea, and history of

Tracheobronchialanterior neck/chest

respiratory disease

embolus, pneumothorax

Pleural-neck, ipsilateral trap/shoulder Hepatic

Hepatitis, cirrhosis, abscess,

Positive risk factors (alcohol abuse,

hepatic metastasis

Biliary

Cholecystitis, cholelithiasis

interscapular/

partners)

subscapular

Prior history of cholelithiasis, epigastriclRUQ pain, fever, nausea

Gastric

Peptic ulcer disease (Gastric or duodenal)

Pancreatic

Pancreatitis, pancreatic

Epigastric/RUQ, right scapula

Epigastric pain, temporal assoc. with meals

Epigastric/LUQ, with

Positive history alcohol abuse,

EpigastriclRUQ, with

carcinoma

Table 35.3

Right shoulder,

IV drug use, multiple sexual

refelTal to back/scapula

history of cholelithiasis

Differential Diagnosis List for Neck

Pain of Musculoskeletal Origin Discogenic Herniated nucleus pulposus with or without radiculopathy or myelopathy Internal disc derangement (annular tear) Facet-mediated pain Capsulitis/synovitis Osteoarthritis Myofascial pain Muscular strain (acute) Muscular overload Trauma Ligamentous sprain Vertebral fractures Instability Degenerative disorders Osteoarthritis Degenerative disc disease Central or lateral canal stenosis Cervical radiculopathy Compressive Inflammatory Thoracic outlet syndrome Supraclavicular (scalene syndrome) Costoclavicular InfTaclavicular Other peripheral entrapment neuropathy Brachial plexus injuries ("stingers & burners")

referral to back/scapula

The BPS reactivation model espouses that pain and disability are not synonymous. The patient should receive reassurance that they are not in danger of making their neck worse with gradual reactivation, but actually will speed recovery and lessen the like lihood of developing a chronic pain syndrome (see Chapter 1 4 ) (65,73 ,95).

Course and Prognosis What Predisposes a Person to Acute Neck Pain? (See Chapter 3)

The incidence of neck pain is quite high. Hill ( 35) estimates that as many as 3 1 % of individuals have had neck pain in the past month.A numbel- of factors have been shown to predispose a person to having an

Table 35.4

Differential Diagnosis List for

Thoracic Regional Pain of Musculoskeletal Origin Thoracic disc herniation Facet mediated pain Costovertebral joint mediated pain Compression fracture Rib fracture Myofascial pain Muscular strain (acute) Muscular overload

856

--


Table 35.5

Quebec Whiplash Associated

Disorders (WA D ) Guidelines Classification System

•

Low expectations of treatment

•

Lengthy duration of current episode

Based on Signs and Symptoms (S7 )

Predictors of Future Pain Grade

Clinical Presentation

o

No complaint or physical sign'"

I

N eck complaint of pain, stiffness or tenderness. No physical signs

II

Neck complaint and musculoskeletal signs'"

III IV

Neck complaint and neurological signs Neck complaint and fTacture or dislocation

" p hysical or m uscul oskel etal signs-range of motion loss or tenderness.

•

High disability score

•

Lengthy duration of current episode

•

Similar problem during the previous five years

Both Hoving and Hill reported that individuals above 40 years of age are more likely to develop persistent neck pain ( 3 5 , 3 6 ) . Although compensa tion has been shown to be predictive of prolonged recovery from whiplash , however Scholten-Peters

(SO) in a systematic review of prospective studies concluded that there is "strong evidence that com pensation has no prognostic value for delayed func tional recovery".

episode of neck pain. Siivola (S2 ) reported that ado lescent neck pain predicts adult neck pain. Also, that psychological stress is a risk factor [or neck pain inci dence. While a reduced risk of neck pain was found amongst those engaged in sports activities involving the upper extremities. Carroll ( 1 5) et al. also found that depression is an independent risk factor for an episode of neck or back pain.

Limitations of Structural Pathology When considering imaging for the cervical spine it is important to know what findings may be relevant or may be misleading. In the neck, the false positive rate for imaging has been reported to be as high as 75% with an asymptomatic population (7,9 1 ) . When com paring patients with radiographic evidence of cervi cal spine degeneration to those without (mean age

What Predisposes a Person to Chronic Neck Pain? (See Chapters 3 and 9)

49 years old), there is no difference in reported pain and disability levels (74). Imaging i s also used t o study spinal alignment

Hill et a!. ( 35) found that 4S% of neck pain patients

and vertebral relationships. However, the cegree of

report persistent pain even] year after onset. Many

cervical lordosis, or lack thereof, has no predictive

risk factors of chronicity are shared by the neck and

value for future neck pain or future degenerative changes (2S).

low back ( 6 2 ) . Feuerstein et aJ. ( 2 6 ) reported that acute neck/shoulder patients who use catastrophiz

Imaging tests have high sensitivity (few false nega

ing as a pain coping mechanism were 1.5 to 2 times

tives) but low specificity (high false positive rate) for

more likely to have pain at ], 3 and 1 2 months.

identifying disc problems. Such poor specificity marks

According to Carroll et al. ( 1 4 ) high levels of passive

imaging as an inappropriate screening method. Bush

coping strategies are associated with disabling neck

found that most cervical disc herniations regress with

or back pain. In particular:

time without resorting to surgery ( 12 ) . Additionally, he found that the larger the disc herniation the more

•

Inability to function with pain

likely it is to reduce in size over time. Therefbre, it is

•

Not taking responsibility for care

important to avoid "labeling" patients as being dam

•

Low self-rated health

Kjellman et al.(50) distinguished between predictors of one year persistence of neck pain or disability and found the following:

Predictors of Future Disability

aged since this may have disabling effects by pro moting the "sick role" and interfering with functional reactivation ( 65). Panjabi theorized that most WAD patients experi ence mild soft-tissue injury which does not cause tis sue failure and thus is undetected by static imaging procedures (72). In these sub-failure injuries the soft tissues are not tom, but are stretched beyond their

•

High pain intensity

elastic limit resulting in functional instability and poor

•

Low self-rated health

healing.


Impairments Associated with Pain and Disability

--

857

repositioning ability or error. Neck pain patients typ ically error in repositioning by at least 5° ( 3 cm),

A number of different functional impairments have been shown to be associated wi th neck related prob lems. For instance, decreased cervical range of motion (ROM) is present to a greater extent .in neck pain than asymptomatic individuals (52 ,53 , 8 9 ) . However, most relevant impairments are related to abnormal motor control; for instance, increased activity in the upper trapezius, repositioning error, and poor con trol of cervico-cranial flexion motion. Edgerton et al. studied altered muscle activation ratios of synergist spinal muscles during a variety of motor tasks in whiplash patients (2 1 ) . They discov ered that underactivity of agonists and overactivity of synergists was able to discriminate chronic neck pain patients fyom those who had recovered with 88% accuracy. They concluded that, "The nervous system apparently can detect a reduced capacity to generate force [yom a specific muscle or group of muscles and compensate by recruiting more motoneurons. This compensation can be made by recruiting motor units from an uninjured area of the muscle or from other muscles capable of performing the same task." Lauren et al. discuss the associations between motor skills and coordination as it relates to neck pain (5 1 ) . This study described appropriate timing and amplitude of muscle reactions and how poor motor control of arm motion was correlated with neck pain. Bansevicious and Sjaastad ( 3 ) reported increased EMG activity of the upper trapezius in patients with cervicogenic headache while perform ing computer tasks requiring concentration. Babyar

( 2 ) reported that fauILy arm abduction related to a disturbed scapulo-humeral rhythm was present in neck/shoulder pain patients. Nederhand et al. demon

whereas normal control subjects error by less than 2°

( 6 3 ) . Cervical mechanoreceptor dysfunction is a likely cause of dizziness in WAD. Increased neck repositioning error has also been found in WAD patients that present with associated dizziness ( 93 ) . Severity o f injury seems significant to joint position error, with deficits noted only in moderate to severely disabled individuals, as measured with the NDI (89). Jull and others have shown that a cranio-cervical flexion test can differentiate asymptomatic individuals fyom patients with various neck related presentations: acute and chronic post-whiplash neck pain patients, chronic headache patients, and non-traumatic neck pain patients (42,43 ,25,45). Jull has concluded that the test cOlTelates with pain (45). During the test both types of patients showed overactivation of the superficial neck muscles (SCM) ( 25,45,89). They also displayed an inability to hold the head at a constant pressure against a pressure sensor at all test levels, as well as an inability to target higher pressure levels

(26-30 mmHg) (42,43,45, 8 9 ) . Falla et al. confirmed that reduced performance of the craniocervical flex ion test is associated with dysfunction of the deep cervical flexor muscles (25). Falla et al. has also demon strated that neck pain subjects had significant dif ference in reaction time for the deep neck flexors in experimental arm elevation. Interestingly, they reported possible bleed over fyom the suprahyoid muscles during the collection on subjects. Manual therapy and exercise to improve the strength and coordination of this movement has been shown to achieve lasting results both in improved function and reduced symptoms.

strated that a decreased ability to relax the upper

Numerous studies have shown that decreased endurance of neck flexors (cranio-cervical flexion

trapezius muscles during static tasks and following

test) (42,43,92, 97) or extensors (modified Biering

exercise distinguished chronic WAD I I patients with

Sorensen Test) (52,53 ) can distinguish neck pain or

marked disability (Neck Disability Index (NDI)

26,

headache patients from asymptomatic individuals.

N ederhand showed in less disabled patients that

correlated with decreased isometric strength and

=

SD 8.5) from healthy control subjects (69) . upper trapezius underactivity is the norm (NDI

Watson and Trott found that forward head posture is

19,

endurance of neck flexors ( 9 7 ) . Silverman found that

SD 8 . 1 ) (70). Increased activity of the sternocleido

individuals with neck pain had reduced neck flexor

=

mastoid (SCM) and anterior scalene muscles during

strength than asymptomatics ( 8 3 ) . Yllinin et al. (99)

low load repetitive upper limb tasks was found in both

reported decreased isometric strength i n neck flex

whiplash or idiopathic neck pain patients compared

ion, extension, and rotation distinguished female

to asymptomatic subjects. (6)

chronic neck pain subjects fyom those without pain.

Bilenkij et al. reported poor motor control (i.e.,

The authors concluded in a related study that the de

impairment) was associated with greater disability

creased strength may reflect reduced pain tolerance

(i.e., functional loss) ( 6 ) .

not an actual strength deficit ( 1 00).

Kinesthetic awareness of position sense has been

Neural provocation tests have been studied for

shown to be compromised in neck pain individuals

their reliability and diagnostic accuracy [or patients

( 1 6,32,33,63,76-78 ,89,93 ) . The ability to find or return

with cervical radiculopathy or carpal tunnel syn

to a specific position of the head in space and is called

drome. The upper limb tension test, which is designed

858

--


to tension and provoke symptoms in the median nerve and/or the brachial plexus, can be considered the "straight leg raise" of the upper extremity. I t has been found to h ave greater diagnostic accuracy than a neurological evaluation i ncluding sensory, motor and renex testing (96).

Effectiveness of Reactivation The Quebec WAD guide l i n e recommended early, ac tive in terven tion (including m anipul a t i o n ) as a basic approach to managing symptoms (73,87). Treat ment following these guidelines has been shown to be muc h more e ffective than traditional passive based care (79). Clinically important sym ptoms at 6 mon t hs post-acciden t were prese n t in only 10% of properly managed patients (early active intervention with sub maximal movements identified by McKenzie evalua tion ) as compared with >50% of those given standard care (e.g., soft collar, i n i tial rest , gradual mobilization) . Similar positive results for early activation were found in other studies. Encouragement to continue with ac tivities of daily living ( ADL's) h ad a superior outcome than prescription of sick leave and immo bilization ( 8 ) . Physical therapy or exac t instruction in se][-mobi l i zation were both better t han 2 weeks rest w i t h a soft collar at I month, 2 month and 2 year fol low-ups ( 6 6 ) . A recent randomized cont rol trial ( RCT) showed that general exercise t reatments or M cKenzie treatmen ts were s l i gh tly m ore effective than low-in te nsity ul trasound (49). McKenzie treat ment led to significantly greater improvement t h a n ul trasound at 3 week a n d 6 m o n t h follow-up period. Chronic pain patients also receive benefit from exer c i se or exerc i se plus ma nual therapy programs. A recent study found t hat chronic neck pain patients receive more benefit from a combination of low tech nol ogy exercise and manipulat ion t h a n w i t h either high-technology exercise o r manipulation alone ( 1 0,24). Most outcomes were similar for the two exer cise groups, except that patient satisfaction was higher for the combined exercise and manipulation group. J u l l demonstrated that manual t herapy combined with exercise training aimed at improving deep neck nexor fu nction improved recovery in chronic neck pain patients following a whiplash i nj ury (44). M obi l ization, manipulation, and exercise were found to be equally effective by Jordan, et al. (4 1 ) . Ahlgren et a1. demons trated t h a t any of 3 types of act i ve care (st rength, endurance or coordination tra i ning) was superior to a group that received only ergonom i c and rel axation advice for im proving chronic work-related neck shoulder pain ( 1 ) . Yllinin '03 studied the e ffectiveness o f exercise for women wit h chronic neck pain ( 9 8 ) . E ndurance training was

most effective, fol lowed by s trength trallllllg, and lastly flex ibility with aerobic conditioning was the least effective.

Outcomes The N D I is a very sim ple, reliable and responsive tool for measuring functional status in individual neck pain patients ( 90). Other scoring tools can be utilized and are reviewed in Chapter 8 . Tu ttle showed t hat "with i n-session" audi ting of pat ient care w i t h tests of the patie n ts mechanical sensi tivity is a val id way to empirically identify manual in terven tions t hat wi l l have lasting "between-session" effectiveness (94).

A Functional Screen

It is fTequently d i f-ficult to pinpoint the specific pain generating tissue responsible for head/neck and upper back syndromes. Even in cases where a tissue-specific diagnosi s is attained, the reasons behind its genera tion are often elusive . For these reasons, and to guide the rehabili tation effort, a thorough f1.ll1ct i onal eval uation is needed . I n fac t , various fu nctio nal deficits (impairments) have been shown to correlate with neck pain (see Chapters 1 and 2 5 ) . An adequate diagnosis for neck patients must include bot h t i ssue-spec i fic elemen ts and fu nctional elements. Functional deficits may be categorized as quanti tative or qualitative. Quan ti fiable f1.ll1ctional tests have been covered in detail in Chapter 1 1 . This section will provide an a tl as of bot h quantitative and qua l i tative test of motor con t rol . Defic i ts in strength, balance, coordination, and endurance represent the spect rum of motor control, which when lacking can place undue mechanical stress on pai n-sensitive tissues, or lead to biomechanically u n favorable compensa tory motor strategies.

The Upper Crossed Syndrome and the Spine J anda emphasized the i m portance of muscle balance in function ( 3 7-40 ). Agonist-an tagonist-synergist relationships should occur wit h proper coordi nation and synergy ( 5 4 , 5 5 , 5 6 , 6 8 , 84). Al terations of this mus cle balance occur in c h aracteris t i c , predi catable patterns ( see Table 3 5 . 6 ) . Add i t ionally, deficits i n mobi lity o f joints near o r remote fTom t h e cervical spine can impact function. Cervical, t horacic, gleno humeral , and tempero-m andibular joi nts should be evaluated for t hese deficiencies. For i nstance, poor thoracic mobi l i ty wil l cause a compensatory reaction i n the cervi co-cranial region or glenohumeral j o i n ts


--

859

Table 35.6 Key Myo fascial or Osteoligamentous Pain Syndromes and M uscle Imbalances Associated with Head and N eck Dysfunction Painful Joints

Trigger Points

Shortened Muscle

Inhibited Muscle

Cervico-cranial Gleno-humeral Upper ribs TMJ

SCM Upper trapezius Scalenes Lateral pterygoids

Suboccipitals Levator scapulae Pectorals M asseter

Deep neck flexors Lower trapezius or subscapularis Diaphragm Suprahyoids

(4, 1 1 ,47,57-60,64). Observation of functional activi ties, eit her in isolated motions, or more complex weight-bearing fu nctions can show t hese differen t motor control strategies a t work, leading t o a bet ter understanding of indivi dual patient function and a customized rehabilitation prescri p tion . A classic example of muscle imbalance is the upper crossed syndrome (see Fig. 3 5 . 1 ) . This is a typical postural overstress resulting fTom muscle imbalance (see Table 3 5 . 7 ) . The overactive/shortened m uscles i nclude the pectorals, upper trapezius, levator scapu lae, sternocleidomastoid ( SCM), masseters, and lat eral pterygoids. The u nderactivelinhibited muscles include the serratus anterior, lower trapezius, deep neck flexor, and suprahyoids muscles. The s ub occipi tals are ohen t i g h t , but also l ose endurance. ( 5 2 , 5 3 ) For instance, whiplash will lead to inhibi tion of the deep neck flexors that will persist for some time aher the i njury (43,4 5 , 9 2 ) . The res u l t of this muscle imbalance is increased kyphosis, rounded shoulders, flexion of the lower cervical spine, exten-

Weak deep neck flexors

Tight upper trapezius and levator scapula

Tight pectorals

Weak lower trapezius and serratus anterior

Figure 35. 1 U pper cross syndrome.

sion of the upper cervical spine and anterior head carriage. The maintenance of spinal stability and integri ty requires efficient load sharing along the kinetic chain. The glenohumeral joint is designed to have great mobili ty but is inherently unstable, and can be easily upset into functional instability. This leads to the a l teration of mechanics and the development of impi ngement or repetitive strain di sorders. If t ho racic mobility is compromised, loads may increase in adjacent segments, typically the cervical spine and shoulder complex. Associations have been shown be tween decreased t horacic extension mobility and both neck pain (4) and shoulder pain (64). Cleland et at. reported t h a t thoracic spine manipulation results in immediate analgesic effects in patients with mechan ical neck pain . ( 1 7) M uscle imbalances are not limited to the axial region. The pattern of over- and under-active muscles extends throughout the extremity (54). Overactive/ shortened m uscles include t h e scapu lar elevators, shoulder internal rotators, shoulder/elbow/wrist flex ors, and forearm pronators. The underact ive/inhibited muscles include the scapular adductors, scapular dep ressors, shoulder external rotators, shoulder/elbow/ wrist extensors, and forearm supinators. The resul t of this muscle i mbalance on the upper extre m i ty is a ltered scapulo-humeral rhythm , anterior/superior migration of the glenohumeral joint , i n ternal rotation and flexion of t he upper extremity, and pronation of the forearm . The scapulothoracic mechanism is the crossroads of the axial and appendicular components of t h e upper quarter. Impaired functional mechanics and scapular s tability are frequently the resu l t of various muscle imbalances and c hanges in mobili ty. Key elements in a treatment approach i ncl ude the restoration joint mobility, normali zation of m uscle activity and endurance, and functional stabi lization of cranio-cervical , scapulo-thoracic and glenohumeral mechanics. M anipulation and mobilization tech niques are of great benefit in the restoration of upper thoracic extension and i mproving other articular restrictions.

860

--


Table 35.7

Relationship B etween Key Sources of Biomechanical Overload and Painful Join ts

Pain ful Joints

Faulty posture

Faulty Movement Pattern

Cervico-cranial Gleno-humeral Upper ri bs TMJ

Head forward Rounded shoulder Slumped posture Chin protrusion

Neck flexion Arm Abduction Respiration Mou th ope n i ng

Overact ive or hypertonic m uscles respond well to muscle relaxation tech niques. I n cases of adaptive shortening or fibrous adhesion, more aggressive con nective tissue or myo[ascial release-type treatments may be necessary. Stabilization exerc i ses are designed to improve motor control and e ndurance. Common elements incl ude lower t rapezius/serratus anterior synergy, deep neck f l exor activity, and t horacic extensor endurance. Closed kinetic chain strategies are o ften helpfu l in es tablishing muscle ac tivation and coor d i nation . Progression can then be m ade to more dynamic, fu nctional activities. The u l timate goal of patien t-specific r,.mctional restoration must be kept in m i nd when designing and progressing exercise.

cranial junction is compromised, thus making the region less s tabl e ( 1 9). Recen t studies h ave identified significan t relation ships, biomechnical and neurophysiologic, that de monstrate functional i n t erplay between the head, neck and jaw ( 2 3 , 3 1 ,34). The first movement during chewing and speaking seems to be extension of the upper neck ( 2 2 , 1 0 1). I mportantly, in WAD patients t his movement is absent. The suprahyoids have received little attention in cervical and TMJ research and/or clinical instruc tion . Several new studies have shown that they act synergistical l y with t he deep neck flexors in provid ing stability to the cervical spine ( 2 9,86)

Atlas of Functional Screens The Upper Crossed Syndrome and the Orofacial Region The oro racial regi o n has a number of fu nctional responsibilities. M astication, swallowing, and speech are t h ree or the most important functions ( 1 9) . The pri mary joi nt complex in t his region is the tempero mandibular joint (TMJ ) , however t he hyoid bone and the cervico-cranial junction are also crucial to function or this region ( 1 9,46, 67). There are many important muscles, but perhaps most important are the supra hyoids, masseters and lateral pterygoids . T h e mai n actions of the j a w are t o open and close. Mouth opening couples m andible depression with c hin retrusion, while mouth c losing is coupled with chin pro t rusion. The suprahyoids produce the action or mouth opening, while the lateral p terygoids bilat era l ly stabil i ze the TMJ. The masseter is the chief muscle responsible for Closing the mouth while i t is assi sted by t h e synergistic medial p terygoids and tempora l i s ( 7 1 ). An individual with a forward head posture typi cally also has t heir c hin protruded and cervico c ranial jun ction hyperextended ( 6 1 , 84 , 8 5). In t his posture the deep neck [Jexors are lengthened while the suboccipitals are shortened ( 1 9,46). The masseter becomes shortened due to increased gravitational challenge while the an tagonistic suprahyoids become r-urther in hibited. Centration of the TMJ and cervico-

The purpose of functional assessment is to identify a patient's functional or performance deficits and capabilities. The modern management of neuro musculoskeletal problems focuses on functional reac tivation, restoration and rehabilitation. Structural problems such as herniated discs or arthritis are rele vant in a small percentage of cases and are often coin cidental findings. Therefore, the functional assessment has become a pivotal and often misunderstood com ponent in patient care. For each test the patient's mechanical sensitivity ( MS ) and abnormal motor control (AMC) is noted. This atlas fol lows a consistent format for describing each test: •

I ndications

•

Procedure

•

Score

•

If positive possible treat ments to consider • Tissue to relax/stretch •

Tissue to adjust/mobilize

•

Tissue to facilitate/strengt hen

This functional assessment does not replace t he ini tial diagnostic triage of patients, but rather comple ments i t . Evidence-based consensus panel guidelines conclude that for over 80% of back pain the exact


pain generator cannot be identified and the label non-specific or mechanical back pain is applied. It is precisely because of this situation that the functional assessmen t is so im portant. Patie n ts want to know what is causing their pain, and while a functional diagnosis does not pinpoint causality i t does give the clinician essential targets for functional reactivation as well providing simple, inexpensive tests that can be used to audit the patien t's progress towards func tional goals and recovery. Choosing t he correct [-unc tional tests is an art not a science. Acute patients wil l receive a fun ct ional assessment limited mostly to range of motion (ROM) and ort hopedic tests. Identifying the movements or positions that reproduce the patient's c haracteristic pain-their MS-is essential on an initial visit. This becomes an essential audit tool (e.g., post-treatment check) for adjudicating and l egitimizing the treat m e n t o r exercise prescription, a n d thus motivating the patient. Once acute pain settles a more compre hensive runctional assessment evaluating AMC can

--

86 1

also be performed ( see Table 3 5 . 8). The tests chosen wil l be based on the functional goals or activity intol erances (AI) of the patie n t . In other words, what activities t hey want or need to do that they are hav ing difficul ty w i t h . For instance, ir sitting is an A I then assessment of mid-thoracic mobi lity, scapulo humeral rhythm, and CO-C l coordination would be appropriate tests.

Table 35.8 Functional Screening Tests ror the Cervi co-Thoracic and Orofacial Regions

1. 2. 3. 4. 5. 6. 7.

Respiration T4-8 screen (wall angel) Push-up Arm abduction Janda's neck flexion test CO-C l flexion Mouth opening

862

--


1 . Respiration Assessment

Test A-Seated

o

Indications •

Su bacu te or chronic musculoskeletal pain (MSP)

•

Poor posture

If Positive Possible Treatments to Consider •

Relax/stretch

•

Scalene P I R (Fig. 3 S . 2 B) Breathing re-educa tion ( Fig. 3S.2C, D) Adjust/mobil i ze

•

Thoraci c spine T4-8 ( Fig. 3 S . 2 e ) Upper costo-vertebral joi nts ( Fig. 3 S . 2 F) Faci l i tate/strengthen

•

Brugger ( F ig. 3 S . 2 G ) Scapul ar depressors ( Fig. 3 S . 2 H ) Functional train i ng

o

Procedure •

•

o

Visually observe the patients normal, relaxed brea t h i ng pattern

o

Manually palpate the lateral rib cage from T6-T I O

o

Score •

Abdomen moves in, rather than out (para doxical respiration-major dysfunction)

o

o

Fa ilure i f during n ormal i n halation: Clavicles or shoulders elevate Lower rib cage does not widen in the horizon tal plane (can be moni tored with palpation)

o

o

o

Breathing during exerl ional exercise

Test B-Supine Procedure •

Visually observe the patients normal, relaxed brea t h i ng pat tern

Score •

Fa ilure i f duri ng normal i n halation: Chest breathi ng predomi nates over abdomi n a l breat h i ng ( m i nor dysfunction) ( Fig. 3 S . 2 A )

o

Figure 35.28 Scalene P I R.

A

c

Figure 35.2A Fau l ty pattem o f chest brea t h i ng .

Figure 35.2C Abdo m i n al brea t h i n g.


o Figure 35.20 Sel r exercise to i n h i b i t chest brea t h i ng.

Figure 35.2G BrUgger re l i e r pos i l i o n .

E

Figure 35.2E Thoracic spine mob i l i zat i on/relaxa t i o n , roam roll-vert ica l .

Figure 35.2H Scapular depressors.

Figure 35.2F U pper r i b P I R mob i l i za t i o n .

--

863

864

-


2. T4-8 M obil ity Screen-Wall Angel Indications •

Su bacu l e or chronic m usculoskeletal pa i n ( M SP)

•

Poor posture

•

Os leo porosis

•

Fac i l i tate/slrenglhen Thoracic spi ne exlensors (Fig. 3 5 . 3 F) Scapu lar depressors (Fig. 3 5 . 3 G ) Stab i l i zation lraining

°

°

•

Core/trunk ( Fig. 3 5 . 3 H , I ) Funct ional train i ng

o

•

Procedure ( Fig. 3S.3A) •

Sland against wall with arms abducted 90°, e l bows ben l 90°, palms supi nated & feet slightly forward

•

Try to flatten back

•

Ask pat ient lo nod so as to Luck their c h i n °

o

o

Backhand (Fig. 3 5 . 3J ) Sword ( Fig. 3 5 . 3K)

Give passive overpressure Lo aid cervico cran ial flexion testing

Score •

Fai l j f Thoraco-I u mbar junc tion does not flatten Record where patient feels tension or pain ( m id-back, left or righ t side, neck) . o

•

•

N oLe i f any symptoms occur when o °

o

Flatte n i ng back Tucking c h i n Wi l h passive overpressure i n to cervi co cranial flexion

Figure 35.38 Pecto ral is major.


Relax/slrelch Pec loralis major (Fig. 3 5 . 3 B )/mi nor, sub scapu laris ( F ig. 3 5 . 3 C ) , upper t rapezius, levalor scapul a (Fig. 3 5 . 3 D ) Brea l h i n g re-education Adj us l/mob i l i ze

o

o

•

o

Thoracic spi ne (T4-8) (Fig. 3 5 . 3 E )

Figure 35.3C Sub scapularis.

Figure 35.3A T4-8 mob i l

Figure 35.30 Levator

ity screen ( wa l l ange l ) .

scapula.


Figure 35.3E Thoracic s p i ne m ob i l i za t i o n , foam roll-hori zont a l .

--

Figure 35.3H Dead Bug o n foam w i t h medicine b a l l overhead.

Figure 35.3F Prayer pos i tion. Reproduced w i t h perm ission fTom L i ebenson CS.

Mid-thoracic dys function (Part Three): Patient

Figure 35.31 Crun c h start p os i t ion-ribs elevated/ i nspira t i o n pos i t i o n , Cru n c h final posi t i o n-ri bs depressed/exhalation pos i t i o n .

self-help. Journal of Bodywork and Movem ent Thera p i es, 200 1 ;5 ;269.

Figure 35.3J Backhand.

Figure 35.3G Wall s l i de. Reproduced w i t h perm ission fTom L iebenson CS.

Mid-thoracic dysfunction (ParI Three): Clinical Issues. Journal of Bodywork and Movement Therapies, 5;269: 200 1 .

Figure 35.3K Sword.

865

866


3. Push-Up Test

o

Indications •

Shoulder pai n

•

Scapu lar o r mid-thoracic pai n

Procedure ( Fig. 3S . 4A) • •

•

Relax/stretch

•

Pectoralis major ( Fig. 3 5 . 4 B )/mi nor, upper trapezius, l evator scapulae Adjust/mobi l i ze o

o

Slowly lower and t hen raise t he tru n k u p

Fai l i f: o o

o

Scapu lae retracts Scapulae wi ngs Shoulders shrug

Thoraci c spine (T4-8) ( Fig. 3 5 .4C) Scapulo-thoracic articulation ( F ig. 3 5 .4D) Glenohumeral joi n t ( Fig. 35.4E) Fac i l i tate/strengthen

o

I n a push-up position from toes or knees

Score •

If Positive Possible Treatments to Consider

o

•

Scapular protraction ( Fig. 3 5 .4F, G) Functional train i ng

o

•

o

o

Backhand ( F ig. 3 5 .4 H ) Punch with cables ( Fig. 3 5 . 4 1 )

Figure 35.4A Push-up test.

Figure 35.4C Thoracic s p i ne mobi l i zat ion, foam 1'0 1 1 hori zo n t a l .

Figure 35.40 Scapu lo-thoracic fac i l i t a t i o n .

Figure 35.48 Pectora l i s major P I R.


Figure 35.4E G lenohullleral manipulalion, caudal gl ide.

Figure 35.4H Backhand.

Figure 35.4F Push-up w i l h plus, a l l fours rock.

Figure 35.41 P u n c h .

i , .. •.

G

\

j

�·'� ;"' 4

Figure 35.4G Push-up w i l h a plus on wal l .

86 7

868


--

4. Arm Abduction-Scapula H umeral Rhythm

Indications •

Shou lder or upper quarter pain

•

Neck pai n , whiplash, or headaches

Procedure ( Fig. 35.5A) •

•


Relax/stretch

•

Upper trapezius (Fig. 3 5 . 5 B ) and l evator scapula (Fig. 3 5 . 5 C ) Adjust/mobilize

•

Thoracic spine (T4-8) (Fig. 3 5 . 5 D ) SC joi n t (Fig. 3 5 . 5 E ) and AC joint (Fig. 35 .5F) G H joint Fac i l i ta te/strengthen

°

Arm at side, e lbow bent 90°, and wrists i n neutra l posit ion

o o o

Slowly raise arm (abduc tion)

Score •

Duri ng t he "se t t i ng phase", first 60°, the shou lder should not elevate

Scapul o-thoracic (Fig. 3 5 . 5 G ) Scapul ar depressors (Fig. 3 5 . 5 H ) Functional tra i n i ng

o o

•

o o

Ergonomic advice (Fig. 3 5 . 5 1 ) Sword pu l l ( 3 5 . 5J )

Figure 35.5C Levalor scapula PLR.

Figure 35.SA Arm abduclion test.

Figure 35.50 Yoga Figure 35.58 U p per t rapezi u s PIR.

s p h i n x on hands.


Figure 35.5E SC joi n t , l o ng axis distrac t i o n .

Figure 35.5H Scapular depressi o n fac i l i ta t i o n .

Figure 35.51 Carry i ng a

Figure 35.5F A C j o i n t manipu l a t io n .

bag, i ncolTect , correct .

Figure 35.5G Scapula-thoracic fac i l i ta t i o n .

Figure 35.5J Sword.

--

869

870

Part Six: Practical Application by Region /

5 . Janda's Neck Flexion Coord i nation Test Indications •

Q

•

Adjust/mobilize

•

Occipu t , upper cervical spine ( Fig. 3 5 . 6 D ) Cervico-thoracic junction ( Fig. 3 5 . 6 E ) Thoracic spine (T4-8 ) ( Fig. 3 5 .6F, G) Sensory-motor t ra i n i ng ( Fig. 35.6H, I)

Neck, whiplash or headache pai n

o

o

o

Procedure ( Fig. 35.6A) •

Slowly raise head up from table toward chest

•

Fac i l i tate/strengthen

•

Brugger (Fig. 3 5 . 6J ) Cervico-cranial flexion motor con trol and endurance trai n i ng ( nodding i n supine, prone, s i t t i ng & standing posi tions) (Fig. 3 5 .6K, L, M ) Functional train i n g o

Score •

o

Fail If o o o

C h i n protrusion SCM overactivity Shaking


Relax/stretch o

o

o

o

Postural exercises ( Fig. 3 5 , 6 N , 0 ) Ergonomi c advice ( Fig. 3 5 . 6 P)

SCM ( Fig. 3 5 . 6 B ) , suboccipitals, upper trapezius ( Fig. 3 5 .6C) Brea t h i n g reeducation

Figure 35.60 Occ i p u t , upper cervical spine.

Figure 35.6A J a nda's neck fl exion test.

Figure 35.6E Cervico-thoracic junction.

Figure 35.6B S C M P I R .

Figure 35.6C Upper

Figure 35.6F ThOl-acic s p i n e mobi l i za

trapezius P I R .

t i o n , roam rol l-hori zon tal .


Figure 35.6G Back stretch over bal l .

Figure 35.6M Nodd i n g u p p e r cervical n e c k fl exion exerc i se.

M

Figure 35.6N Wal l s lide. Reproduced with permission fTom Liebenson CS.

Figure 35.61 Figure 35.6H

Forward

Rocker board.

lean.

Mid-t horacic dys funct ion ( Part Three) : C l i nical Issues. Journal of Bodywork and Movement Thera pies, 5 ;269: 200 1 .

N

Figure 35.6J BrUgger rel i e r pos i t i o n .

Figure 35.60 Ball squat.

Figure 35.6K Cervico-cran ial nexion w i t h stabi l i zer cufL

P

Figure 35.6P Push i n g a s t ro l l er, correc l , Figure 35.6L Prone s p h i n x with chin tuck.

i ncorrect.

--

871

872

--


6. Cervico-Cranial Flexion Indications •

N eck pai n , whiplash, or headaches

Procedure ( Fig. 35.7) •

Patient demonstrates nodd i ng motion If patient is u nable then c l i nician models motion on patient u n t i l t hey are able I nn ate cuff to 20 m m H G

o

• •

•

W i t h t he c h i n nod motion, patient i ncreases pressure to 22 m m H G & h olds for 1 0 seconds

7. Mouth Opening (Orofacial Coordination)

Indications •

TMJ/orofacial pai n, headac he, neck pain

Procedure: ( Fig. 35.8A) •

Patient is i nstructed to ope n their mou th fu l ly

Score •

Fail i f: o

Patient tries to i ncrease pressure to 24, 26, 2 8 a n d 30 m m H g holding for 1 0 seconds w i t h a rest period a fter eac h new level

o

o

Score •

Fai l i f: o

o

o

Overactivation of the superficial neck muscles (SCM ) I i nabil i ty to hold a constan t pressure at specific test l evel I n abi l i ty to ac hieve h igher pressure levels ( 26-30mm Hg).


( s i m i l a r treatments as Janda's neck flexion coordi nation test)

C h i n protrusion ( Fig. 3 5 . 8 B ) Decreased R O M ( less than 3 knuckles verti cal clearance) Head extension


Relax/stretch Sub occi pitals, lateral pterygoids, masseters ( Fig. 3 5 . 8C) Adj ust/mobilize o

•

TMJ (Fig. 3 5 . 8 D ) Hyoi d mobili zation ( Fig. 3 5 . 8 E ) Occiput, upper cervical spine ( Fig. 35.8F) Thoracic spine (T4-8 ) ( Fig. 3 5 . 8G ) Fac i l itate/strengthen

o o o o

•

o

o

Retrusion re-train i ng ( Fig. 3 5 . 8 H ) Suprahyoids

Figure 35.8A,B (A) M o u t h ope n i ng test

(B)

mandi bular protrus ion. Liebenson CS.

Advice for the c l i n ician and pat ient: M i d t h oracic dysfunction ( ParL One) : Overview

Figure 35.7 CO-C I nexion LesL.

and Assessmen L . Joumal of Bodywork and Movement Therapies, 200 1 : 5;96.


--

Figure 35.8F Occ i p i ta l l i ft .

Figure 35.8e Masseter P I R .

Figure 35.8G Thoracic spine m o b i l i z a t i o n , foam roll-hori zan tal .

Figure 35.80 TMJ mob i l i za t i o n .

Figure 35.8E Hyoid mob i l i za t i o n . Figure 35.8H Man d i bular retrusion re-tra i n i ng.

8 73

874

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Cases

This section w i l l detai l a few examples of common c l i n ical presenlations. A common format i ncorpo rat i ng the d i fFeren t key e lements of care i n to a re pealable prac tice model w i l l be s hown ( see Tables 3 2 . 7 , 3 2 . 9 and 3 2 . 1 0) (48 ) . J(jbler's fun c tional kinetic chain model will be presented for each case to show how management should not be guided only by an orl hopedic assessment of lhe pai n generator, but be pred icaled on a f-tmc l i onal assessm e n t (see Table 3 2 . 7 ) (48). Add i tionally, the goals of care will be pre sen led for eac h case ( pall i ative, tissue sparing, t i ssue stab i l i z i ng, and funct ional trai n i ng ) ( see Table 3 2 . 1 0). W i l h i n t hese goals of care are subsumed the con ti nuum or s teps o f care ( advice, manipulation, and exercise) iden l i fied/discussed i n Chapter 32 (see Table 3 2 . 9 ) . For example, sparing strategies i nclude advice on ergo n o m i c modi fications or m a ni pu la lions of joi nts or soft ti ssues; and exercise is included in both stab i l i z i ng and functional t ra i n ing.

thoracic kyphosis ( Fig. 3 5 . 9 D ) , and/or sh rugged shoulders due to fau lly scapulo-hu meral rhythm ( S H R ) duri ng: •

• • •

Dysfunctional kinetic chain: •

• •

Palliative care: Reduce i rri tabi l i ty of cervico

cranial and related myofascial tissues Sparing strategies: •

Kinetic Chain Approach

•

Clinical symptom complex: Head pai n b i laterally,

•

Tissue injury complex: D ifferential diagnosis ( D Dx)-myo fasci a l , zygapophyseal Source of biolnechanical overload: Forward head

with cervico-cranial hyperextension and cervico-

Inhibited deep neck flexors, faul ty SHR, faulty push-up Hypomobi l i ty o f m i d/upper thoracic spine Hypertonic SCM, cervical extensors (sub occipi tals), upper lrapezius and levator scapul a

Goal and Continuum of Care

Case 1 : Neck Pain and Non-Migrainous Headache

lypically loca l i zes in the supraorbi tal or suboc cipilal region, o ften presents with restricted cer vical ranges of motion and associ aled neck pain ( Fig. 3 5 . 9A, B , C)

Prolonged sitting ( Fig. 3 5 . 9 E ) , and computer activity ( Fig. 3 5 .9F) Sleep ergonomics ( Fig. 3 5 .9G) Carrying ( Fig. 3 5 . 9 H ) Push-up, curl u p , bench press, latissi mus pull -down ( Fig. 3 5 . 9 1 )

•

Activity modification advice (avoid pro longed readi ng, writ ing, computer activi t ies and postural awareness [raini ng) ( Fig. 3 5 . 9J ) Sleep ergonomics ( Fig. 3 5 .9K) Adjust/mob i l i ze thoracic spine (T4-8 ) (Fig. 3 5 .9L) Relax/lengthen upper trapezius ( Fig. 3 5 . 9 M ) , levator scapula, cervical extensors & SCM

Stabilizing strategies: • •

Facilitate deep neck flexors ( Fig. 35.9 N , 0, P) Scapul ar depressors (Fig. 35.9 Q , R, S)

Functional training: •

Reeducale postural awareness duri ng reaching overhead, pul l i ng, pushi ng, l i ft i ng, bending ( Fig. 3 5 . 9 T, U, V)

Figure 35.9B Referred pa i n fTom SC M .

Figure 35.9A Referred pain A

fTom u pper trape z i us.


--

875

Figure 35.9F Typi cal slouched desk posture.

Figure 35.9C Referred pain from cervical spine j o i n l s .

Figure 35.9G Excessive p i l low support.

1X

Figure 35.90 E ffecls of

2X

posture on neck muscle activity.

o

Figure 35.9E Slouched posture.

3X

H

Figure 35.91 I m proper form

Figure 35.9H Carrying

d u r i n g "lat p u l l dow n "

a bag i ncOlTectly.

exercise.

876


Figure 35.9N Cervico-cra n ial Ocxion w i t h s tabi l i zer cu ff.

Figure 35.9J B rugger re l i e f pos i l i o n .

K

Figure 35.9K I deal p i l l ow support.

Figure 35.90 Nodding upper o

cervical neck Oexion exercise.

Figure 35.9L Thoracic spine mobi l i za t i o n , foam roll-hori zontal .

Figure 35.9P Prone s p h i n x wi t h c h i n tuck. Figure 35.9M U p per trapezius P I R .


--

T

Figure 35.9T W a l l sl ide. Reproduced w i t h perm ission [Tom L iebenson CS. M i d-thoracic dysfu n c t i o n ( Part Three): C l i nical Issues. Journal o f Bodywork and Movemen t Therapies, 5 ; 269: 200 1 .

Figure 35.9Q Scapular depression fac i l i ta t i o n .

Figure 35.9U Sword.

Figure 35.9R Scapulo-thoracic facil i ta t i o n .

Figure 35.9V S ingle arm row, (V) correct

(W)

i ncon-ect . Reproduced w i t h perm ission

from Liebenson CS. Self-management of shoul der disorders. Journal o f Bodywork and Move

Figure 35.95 Push-up, a l l fours rock.

ment Therapies, 2005; 9 : 20 ] .

877

878

--


Case 2 : Temporomandibular Joint Syndrome

Kinetic Chain Approach

Sparing Stra tegies:

Clinical symptom complex: Pai n and c licking dur

•

ing mouth opening and closing (Fig. 3 5 . 1 0A ) •

Tissue injury complex: DDx-condyle/disc com

plex, myofascial Source of biomechanical overload: Mandibular

protrusion ( Fig. 3 5 . 1 0B ) , overactive mandibular elevators and upper cervical extensors.

•

Stabilization Strategies: •

•

• •

Facil i tate suprahyoid muscles

Functional Training: •

Dysfunctional Kinetic Chain: •

Release masseter (Fig. 3 5 . 1 0D), lateral p terygoid, sub-occi pitals Mobil ize condyle-disc complex (Fig. 3 5 . 1 OE) Mobilize CO-C l junction

Weak activation of suprahyoid musc les Poor cranio-cervical s tabil i ty and endurance for head/neck tasks (e.g., sit ti ng, curl up, speaking) Poor swallowing Poor respiration ( Fig. 3 5 . 1 OC)

Reeducate mandibular opening and resting posi tions ( Fig. 3 5 . 1 0F)

Goals and Continuum of Care Palliative Care: •

•

•

Reduce i rri tab i l i ty condyle-disc complex (e.g., moist h eat, i ce) Ac tivi ty modifications (i.e., teach mandibu lar rest position) Behavior modifications (e.g., clenchi ng, bruxism, tongue habits)

c

Figure 35. 1 0C Faul ty pat tern o f chest breat h i ng.

A

Figure 35. 1 0A Masseter trigger p o in t referral pattern. Masseter t rigger po i n t repri nted with permission from Chai tow L. C l i n ical Appl ication of Neuromuscular Tech n i ques, Vol J , C h u rc h i l l Livi ngston e , E d i nbrgh 2000.

Figure 35. 1 08 M a n d i bu l a r pro tru s i o n . L iebenson CS. Advice for the c li ni c i a n and patient: M i d t horaci c dysfu nction ( Part O n e ) : Overviw and Assessme n t . Journal of Bodywork a nd Movement Therapies, 2 0 0 1 : 5 ;96.

Figure 35. 1 OD Masseter P I R .


--

Figure 35. 1 0E T MJ mobil i za t i o n .

Figure 35. 1 0F M a n d i b u l a r ret rusion re-trai n i ng.

879

880

--


Goal and Continuum of Care

Case 3 : Cervical Discogenic Radiculopathy

Palliative care:

Clinical symptom complex: Nerve root symptoms down t he arm and/or m edial scapular pain aggravated by various neck postures and movements

•

Sparing Strategies: •

Tissue injury complex: Nerve root compression or

tension due to disc hern iation Source of biomechanical overload: •

•

•

End range loading of disc during ADL's poor sitting or sleeping ergonomics ( Fig. 3 5 . l l A, B ) Pert i nent factors i nclude: Temporal - morning or after prolonged flexion (sitting, stooping) Poor postural a nd breath i ng habits lead i ng increased t horacic kyphosis and head Forward posture -

•

o

• • •

Dysfunctional kinetic chain:

•

Ergonom ic workstation ( Fig. 3 5 . 1 1 1 ), sitting (Fig. 3 5 . 1 1 1) , and sleep ( p i llow) ( Fig. 3 5 . 1 1 K) advice Avoid peripheralizi ng positions/movements (e.g. , cervical extension) and perform cen tralizi ng posi tions/movemen ts (e.g., cervical retraction) ( Fig. 3 5 . 1 1 L) Perform cen tralizi ng activities (e.g., sleep w i t h arm overhead (Bakody's position)

Stabilizing Stra tegies:

o

•

Ice, anti-inflammatories, cervical collar, traction ( Fig. 3 5 . 1 1 H )

Increase mid-thoracic extension mobi l i ty Train scapular setting Train deep neck flexors

Functional Training:

I de n t i fy central i z i ng and periphera l i z i ng maneuvers ( Fig. 3 5 . 1 1 C , D ) Perform upper l i mb tension tests ( Fig. 3 5 . 1 1 E, F, G )

• •

M c Kenzie prac t i tioners w i l l l i kely a t test t o the fre quent d i fficulty in i n i tial ly attai n i ng a cen tralizi ng posi tion or m ovement in the acute case ( see C hapter 1 5 ) . Perhaps t h i s can be attributed to a more active i n flam matory component (chem ical radicul itis). This will certai nly l i m i t , but does not exclude functional exam i nation. Mechanical d i rectional sensi t ivity should be noted, i f present. Sensi tivity to neural ten sion tests may be helpful i n establishing what move ments are sare to pursue, and what should be i ni tially avoi ded ( see Chapter 20). As time and early pain based i n tervent ions take effect, a clearer picture of h.lnctional defic i ts wi l l emerge, and a more spec i fic reactivation and ru nctional restoration program can be ad ministered.

Squats/lunges Push/pu l l

Figure 35. 1 1 8 Lack o f p i l low support.

c

Figure 35. 1 1 A Slouc hed posture.

Figure 35. 1 1 C S i t t i n g retract ion-extens ion .


Figure 35. 1 1 H P I R trac t i o n o f cervical s p i n e using respiralion only.

H

Figure 35. 1 1 D Pro molion of cervical flex i o n .

Figure 35. 1 1 1 Proper desk posture.

Figure 35. 1 1 E Upper L i m b Neura l Tension Test

( U LNT), median nerve.

Figure 35. 1 1 J Upright posture.

Figure 35. 1 1 F U LN T

Figure 35. 1 1 K

test, radial nerve.

Ideal p il l ow support.

Figure 35.1 1 G

Figure 35. 1 1 L

U L N T test , u l nar

Cervical

nerve.

retrac t i o n .

J

L

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88 1

882

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Audit Process

Self-Check of the Chapter's Learning Objectives What rehab i l i t a t i o n m e thods should be consi dered

•

[or dysfu nctional neck flexion? W h a t reha b i l i tation m e t h ods should be considered

•

for a dysfu nc ti o n al scapulo-humeral rhyt h m ? What i s t h e con t i n u u m o f care for cervical n e rve

•

root syndromes What is the c o nt i nu u m of care for orofacial

•

problems?

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8 1 . Scien t i fic Advisory Board. C l i nical prac t i ce gui de l i nes for the d i agnosis and m anagement of osteo porosi s . Canad i a n M e d ical Assoc i a t i o n Jou rnal-su pplement 1 996; 1 5 5 : 1 1 1 3- 1 1 3 3 .

9 7 . Watso n , D H , Tro l l P H . Cervical Headache: a n i nvest igation of natural h e a d posture a n d cervical flexor m uscle performance. Cephalgia 1 99 3 : 1 3 ; 2 7 2-2 84.


98. Y l i nen J, Ta kala E P , Nykanen M , H a k k i ne n A, M a l k i a E, Pohjolainen T, Karppi S L , Kaut i a i ne n H, Airaksi nen O . Act ive neck muscle trai n i ng i n the treatment o r chronic nec k pai n i n women : A ran domi zed con trolled tri a l , " J A M A 2003;2 8 9 : 2509-25 1 6 . 99. Y l i n e n J , Salo P, N y kanen M , Kau t i a i nen H , H a k k i nen A . Decreased isometric neck strength i n women wi t h chronic neck pain a n d t h e repeatabi l i ty or neck strength measurem ents. Arch Phys Med Reha b i l . 2004 ; 8 5 : 1 3 03-8.

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1 00 . Y l i ne n J , Takala EP, Kaut ia i ne n H , Nykanen M , Hakkinen A , Pohjolainen T , Karppi SL, Airaksine n O . Assoc i a t i o n o f n e c k p a i n , d i sabi l i ty a n d n e c k p a i n duri n g m ax i ma l effort w i t h neck m u s c l e s t re n g t h a n d range o f move m e n t i n w o m e n w i t h c h ro n i c n on-spec i ri c neck pai n . Eur J Pai n . 2 0 04 ; 8 : 4 7 3-8. 1 0 1 . Zafar H , Nordh E , Eri ksson PO. Spatiotemporal consi stency o f human mandi bular and head-neck movement trajectories during jaw ope n i ng-clos i ng tasks. Exp Bra i n Res. 2002; 1 46 : 70-6.


PART

Implementing the Functional Paradigm

CHAPTER 36

The Patient and the Doctor


Editor's Note This section offers a multidisciplinary vision or how the self-management model presented in this

CHAPTER 37

book is applicable to all specialists in the neuro

The Role and Safety of Activity

musculoskeletal field. In fact, the core competen

in the Elderly

cies required of conservative care specialists can

Craig Liebenson

now be outlined so that both small private prac

ApPENDIX 37A

benchmark themselves according to the modern

tices and larger multidisciplinary clinics can Physical Activity Readiness Questionnaire CHAPTER 3S

Role of Non-Operative Spinal Specialist in Managing the Spine Patient

Joel Press, John J. Triano, Craig Liebenson, and Robert Watkins CHAPTER 39

From Guidelines to Practice: What is the Practitioner's Role?

Alan Breen

clinical framework. "Best practice" approaches require best evidence synthesis, practice integra tion, outcome assessment, and finally re-evalua tion. Through this process, leaders in the musculoskeletal field can offer practitioners in the trenches a vision of excellence. Each individual practitioner can utilize the simple audit process presented in the book's final chapter to evaluate how close they come and what changes are required to achieve a "best practice" approach.


The Patient and the Doctor


Our Relationships The Individual The Environment

Learning Objectives


Listening: An Essential Skill Managing Several Problems at the Same Time The Hawthorne Effect Obtaining the Patient's Confidence Interaction The Whole Person How Symbols and Metaphors Work Restoring the Patient's Self-Respect

•

•

•

Understand the importance of the doclor-patienl relationship to positive outcomes Understand how to respond lo patients presenting with different emotional make-ups or attitudes Gain insight into the value of enhanced listening skill Appreciate the role of prayer and coping From Chaos to Order. We remind ourselves that

heavy doors move on small well-oiled hinges. Study

Prevention: Promoting Health

of chaos theory teaches us that small changes at

Education

the beginning of a sequence often lead to large

The Fitness Center

changes at the end, as a state of chaos leads to one

The Spandex Bodysuit Spiritual Factors in Healing Help From New Scientific Advances Religion and Healing

of new order. This is particularly true in the case of rehabilitation of spinal disorders and allied lesions. In this we have to deal with a number of nudges, listening, compassion, caring, understand ing, and togetherness that have such a big effect

Either/Or: BothlAnd

healing and, on the other hand, ripples such as

Chaos Theory, Nudges, and Ripples

stress, anger, anxiety, and uncertainty that hinder

Other Resources

the patient's recovery. The attitude of the patient

Publications

and of the physician is as important as the modal

The Power of Prayer

ity of treatment that may be chosen.

889

890

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Part Seven: Implementing the Functional Paradigm

Our Relationships

The interaction between medical doctor and patient, chiropractor and patient, and medical doctor and chiropractor embraces these three and their envi ronment. These relationships to one another matter more than any individual factors. John Macmurray (1,2), professor of philosophy at London University in the 1930s, defines the scope of human relationships.

PHYSICAL

EMOTIONAL

"In the realm of science, the unbiased observer records

COGNITIVE

SPIRITUAL

facts [Tom the world around us ...In the field of art, the observer is involved in a pel"sonal assessment of the objects studied ... In the sphere of religion, two or more people are involved in personal interaction."

In other words, it is better to rely on simple kinds of therapy than on major interventions such as another operation. Recovery [Tom major surgery is largely dependent on simple methods of rehabilitation. Treat ment of a patient by one therapist in a simple friendly selling is more likely to enhance recovery than treat ment by many different therapists in a large imper sonal selling. We see this in the world around us equally well. The transistor, initially small and crude, has replaced the thermionic valve. Small steel mills, initially looked on with disdain, now produce as mush steel as the remaining large mills. The personal computer has, to a large extent, replaced the large departmental computer. In rehabilitation, for the most part, small is beautiful. The use of the so-called disruptive techniques initially are for convenience, ease of use, and cost-effectiveness and only later for improved performance.

The Individual It is convenient to regard each person as made offour different, yet interconnected, parts: the physical, the cognitive (logical), the emotional (intuitive), and the mental (spiritual). This can be illustrated simply by drawing a circle that represents the individual, divid ing it into four quadrants, and imagining a door between each division to illustrate the connection between the parts (Fig. 36.1). A practical application follows. Each one of the four parts influences the oth ers. There is a big difference between the treatment of a disk herniation in a person who is in good men tal, emotional, and spiritual health and one in an indi vidual who has mental or emotional problems. A complete diagnosis includes the other three compo nents as well as the physical findings. It is often easy to treat a patient with a sacroiliac syndrome who is otherwise in good health, but the same treatment is difficult in an individual who is resentful toward her employer.

Figure 36.1 Four aspects of personality.

The Environment

The environment also can, for convenience, be con sidered in four parts (Fig. 36.2): the workplace; the home; the social gathering, consisting of activities in the club or the church; and the patient's hobbies and interests. There is further interaction between the individual and the different parts of the environ ment. A simple practical application follows. The diagnosis must include not only the physical or men tal problems within the individual but also how the patient feels about life at work, at home, and in the external environment. A facet syndrome may be a minor problem in a person who is happy at work and at home. A sacroiliac syndrome may present a difficult problem for a person whose spouse is un sympathetic. In prescribing treatment, the answer may be found by introducing a change in the workplace or adjust ment to life in the home rather than in chiropractic manipulation or drug, injection, or other therapy. The writer recalls the case of a young man with symptoms suggestive of a cauda equina syndrome who recovered rapidly when plans were made for his mother-in-law to take a long vacation in a distant part of the country. The wise physician, chiropractor, or physical ther apist sees the patient as someone with these four parts to their make-up living in a four-part environ ment. Practitioners cannot help every patient with all possible aspects of their problem, but they may need to approach the problem in greater detail sometimes. Often it is helpful to allow the patient time to tell all he or she wants to say about himself or herself. We should be as prepared to refer a patient to a social worker, industrial adviser, or psychologist as we would to a neurosurgeon or orthopedic surgeon.

Chapter Thirty-Six: The Patient and the Doctor

--

891

HOME AND FAMILY

t t HOBBIES (INTERESTS)

.. �

® C

S

t t

WORKPLACE

Listening: An Essential Skill

In this it is helpful to accept the framework of the whole creation, the actual nature of our world, and of all of us in it and to appreciate our place in it. This is difficult to do. For our good fortune, "epistemology models ontology." What we can know is a good guide to the W3Y things really are. A study at the University of Minnesota suggests that 60% or misunderstandings in business result from poor listening. Eight percent of all business communications must be repeated. Rarely is more than 20% of what top management says understood five levels below. Sixty percent of customers who stopped buying from a company did so because of poor listening, an attitude of indifference to the client. Eighty percent of the day in business is spent in communication, but time spent in listening is often at only a 25% efficiency level (3). Poor listening skills are responsible for many of our failures and for much dissatisfaction felt by our patients. Dr. Bernard Lown of Harvard, cardiologist and Nobel Prize winner, has stressed the importance of taking time to listen to the patient. In his opinion it is essential to spend an hour with the patient on his or her first attendance. Frank discussion of religion has often been diffi cult, awkward, and sometimes taboo. It has taken three or four hundred years to recover from the dic tum propounded by Descartes, who taught that the mind and the body are two separate entities in any individual. For many years, both doctor and patient have felt uncomfortable discussing religious matters. This attitude is changing, however. Many of us now feel at ease when talking about our world, our universe, and our Creator. The approach of many, particularly younger people, to this subject is often one that differs fTom beliefs once considered ortho dox. As physicians, we need to keep open minds with respect to different ideas and beliefs. The good physi cian sits beside the patient prepared to listen, rather than standing over the patient or sitting behind the

SOCIAL

.. •

(CLUBS, CHURCH)

Figure 36.2 The individual and the environment.

desk, prepared to make pronouncements about the individual's health.

Managing Several Problems at the Same Time

Although a great deal of our work helping people back to health is quite straightforward, it often can be difficult and tax our capacities to the limit. Ack hoff, an expert adviser and writer on the subject of business and industrial management, commented, as quoted by Dixon, (4) that problems in these areas rarely occur in isolation. In a plant or factory, several problems typically exist at the same time: they are constantly changing and interacting with another. Ackhoff calls this continuing process a "mess." In his opinion, a good chief executive officer is not merely someone who can manage a problem, but one who maintains control when coping with a "mess." From this discussion of the individual and the environment, it is easy to see the common ground between the business executive and the health care professional. In helping his or her patients, the physi cian or chiropractor must be prepared to deal with this "mess" frequently. To realize that health cal-e provider- patient situations often are Ii-aught with this kind of difficulty is to minimize the stress expe rienced by the therapist. In addition, it enables him or her to understand more easily the thoughts, feel ings, and attitudes of the patient. It is curious that we human beings have two oppos ing facets within us. On the one hand, we want to be different, stand out among our fellows as brilliant football player, top of the class, or receiving early promotion; on the other hand, we want to merge with the crowd, have the same ideas and habits, and wear the same sort of clothes. These warring factors make the "mess" more complex. Of the many ways to deal with this "mess," the most valuable is laughter, with and not against some one else, often about something ridiculous. We can

892

--


sit beside our patients, chatting naturally, getting them to laugh, laughing with them, sometimes when necessary being ourselves the butt of the joke to enhance the interaction.

The Hawthorne Effect

(5,6)

The management at the Western Electric Plant at Hawthome in the western United States was anxious to improve the output of the workers. They employed a team of sociologists who visited the plant, talked to the workers, and inspected the workshops. Among other things, they decided to increase the lighting in several areas. At once, the output fTom the workers increased dramatically. Everyone was delighted. At this point, one of the visitors suggested a further change. They told the workers that they planned to help them further but were careful not to say what they intended to do. They then decreased the strength of the lighting to a point below the original level. To the surprise of the management, the output of the workers increased still further. In fact, the workers had been influenced not by the strength of the light but by the feeling that both management and the team of sociologists were interested in their welfare. In commenting on the Hawthorne effect, Dixon notes that the scientist, in designing experiments, does his or her best to minimize or eliminate this phenomenon, which is one kind of placebo effect. Dixon thinks that using this effect forms the basis of a good deal of his practice and is a central feature of family medicine. The author concurs in regard to his pl-actice as well.

Obtaining the Patient's Confidence

The effect of pulling the preceding principles into practice in our office and clinics is to build up a patient's confidence in him or herself as well as in the provider of health care. Our interaction with each patient should begin with a friendly greeting, a handshake, walking with him or her fTom the waiting room to the office, and sitting beside him or her and not behind our desk. These things are little but very import ant and repre sent the invaluable combination formed when patient and therapist work together. Legend has it that in teaching his apprentices, Hippocrates stressed the value of obtaining the patient's confidence. It is reported that he went so far as to say that even in cases of the direst of diseases, ,

the contentment engendered by the patient's convic

tion of the real concern of the physician could be the

main factor responsible for a cure. To this, Sir William Osler, Professor of Medicine first at McGill, then at Hopkins, and finally at Oxford University, added that in his opinion the character of the patient with a particular disease was more important than the nature of that disease. Chiropractors have an advantage in that their particular skill requires them to lay hands on their patients. This action itself induces confidence. The rest of us should share this advantage, by touching the patient with our hands during the examination and placing a reassuring hand on his or her shoulder when saying goodbye. In referring to a specialist, one patient said, "He never laid a hand on me to examine Ole. He came into the room, greeted me briefly and then asked his resident to tell him what he had found. Then he told me I would need a CT scan, a myelogram, and an operation. I was not satisfied. I said I would think it over. I didn't go back to see him again."

Interaction

Discussion of the ways in which one may increase the patient's confidence leads us to consider the interac tion that takes place between the doctor and the patient. We would like to be able to make a concise and complete objective diagnosis in every case but this is often not possible. One of my patients was an elderly widow who lived by herself in a small prairie town in Saskatchewan. She first presented with a sacroiliac syndrome that did not respond to manipu lation but became symptom free after an injection to the sacroiliac joint. She returned with the same symp toms a few months later, which again responded to injection. This happened sevemltimes over the months, always with the same satisfactory result. EventuaJJy I realized that the real problem was loneliness and boredom. This was in fact relieved temporarily by a trip on the local bus, a visit to the hospital, and some talk and encouragement from me, incidentally accompanied by an injection to the sacroiliac joint, the whole giving her an enjoyable outing. This kind of problem is not uncommon. The counterpart to this phenomenon is found in quantum physics. At the beginning of this past century, Max Plank and Albert Einstein made the discovery that light, energy, and mass all could be described as waves or as small par ticles (quanta), depending on how the experiment was set up. The Danish physicist, Nils Bohr, solved the problem when he postulated that the right ap proach was a subjective one in which the interaction of the observer, looking for waves or [or particles, was the determining factor. Einstein found this difficult to accept!


The Whole Person Obtaining the patient's confidence stems from our

--

893

Restoring the Patient's Self-Respect

regarding him or her as an entire, integrated being,

Fortunately, it is usually not difficult for the caring

a unity, someone of value, with the physical, mental,

physician or chiropractor to help the patient regain

emotional, and spiritual working in combination.

his or her feeling of wholeness, belonging, and worth.

This draws attention to an important observation,

The physician or other health care provider can lis

already considered to some extent: as we look on our

ten carefully and with concern to the patient's account

patients, set out to diagnose their ills, and attempt to

of the assault on his or her dignity. Some sample ex

treat them, we must think of them, all the time, as a

changes follow:

whole man or woman, an individual person in their own particular environment. In so doing, we try to

•

exert empathy to get alongside the patient, almost as

He or she can then say "I agree, this is thoroughly bad, let's see what we can do about it together."

a part of him or her, to help solve the problem. •

The patient can be seen as o ften as is necessary to help him or her feel happy, free

How Symbols and

from embarrassment and at ease again.

Metaphors Work •

The practitioner can put himsel f

or

herself in

The use of symbols and metaphors has a powerful

the patient's shoes, saying, "Yes, if that

effect on the patient. They help the patient overcome

happened to me I would be really mad."

the feelings of loss of wholeness and oneness, loss of control, vulnerability, and isolation from friends, rel

•

atives, and colleagues. lung found that the subcon

procedure. I can imagine how you felt."

scious of his patients was teeming with symbols! Symbols and metaphors are very personal. Each

•

Another patient said, "Once I had a catheter passed by a rough, inexperienced assistant. I t

individual has the ability to make his or her own sym

was very painful. I n m y case, I was told not to

bols. Sometimes, external events over which we seem

be a sissy. I decided not to go to that surgeon

to have no control make symbols for us. Groups of

ever again unless driven to it." The physician

people and nations also have their symbols. A symbol

replied, 'Td make the same decision myself."

often, perhaps always, carries more weight than logic. The situation in which we find ourselves is not

The practitioner can say, "After what you have told me, I would be reluctant to undergo that

•

A physician said to a patient, "Yes, some years

always friendly. Friends, acquaintances, doctors,

ago, like you, I had on one occasion to take all

nurses, and even chiropractors can disturb the work

my clothes off and wait for the doctor while

ing of our symbols and metaphors by their attitude,

standing in front of five or six men and women.

their thoughts, their words, and their actions. All of

They seemed to be enjoying my predicament."

us to ou r shame can recall examples of being abrupt, unkind, or unfeeling in treating a patient. Reminding ourselves of such occurrences encourages us to do better in the future. The following scenario occurred in a major teach ing hospital. A patient was taken to the operating room for a cystoscopy, from the ward, without any preoperative medication. He had to get himself across from the stretcher to the operating table. His legs were placed in stirrups, with all of him in full view o f all persons i n the brightly lightly room. The surgeon then injected a local anesthetic per urethram. A few minutes later, the cystoscope was passed, a painful procedure. This experience o f both pain and embar

All of these situations sound ridiculously simple. The reader may think that they are not helpf-ul. I believe they are extremely important for ensuring a fruitf-ul interaction between patient and physician, chiroprac tor, or other provider of health care. Certainly, the patient can do some things for the doctor or chiro practor: having a bath before their appointment; wash ing the feet thoroughly; and weming clean underwear. It is good to follow Dr. Craig Liebenson's advice. He often asks the chronic pain patient if he or she is frustrated or angry about their pain or disability. They usually say yes. It is a relief to have their emo tions validated.

rassment a ffected the patient adversely, leaving a permanent scar, with fear of and dislike for the urol ogist. A few changes in procedure, a few minutes of

Prevention: Promoting Health

explanation by the surgeon the previous evening, and

The most important measures for the f-

some arrangements for more privacy could have

realm of prevention. Fortunately, individuals now

made the whole procedure less traumatic, both phys

involved in health care are concerned with the promo

ically and symbolically.

tion of active health and not just with the correction of

894

--


a disease process. This cogent lesson has been learned

that the patient acquires in the back school is in due

mostly in the field of sports medicine. The rest of us

course of benefit to the comm unity as well.

owe a debt of gratitude to the pioneers in this field. Our motto should be "health through activity." The writer made this simple but vital discovery while treating Anican patients with tuberculosis of the spine. While lying in a plaster of Paris shell during recovery after a spinal fusion, the patient was instructed to move arms and legs to m usic several times per day. Rest was essential for the healing of the spinal lesion. Activity of arms and legs was very important for promotion of the circulation and thus for a sense of well-being and of the general health of the whole patient. The tools and resources needed for disease pre vention are well known. We need to now refine and develop them. That chiropractors and medical prac titioners have learned to work together in harmony is probably the most significant advance in the field of m usculoskeletal illness and its treatment. These professionals have different yet complementary skills and attitudes. For the past 25 years of prac tice, my work, in increasing cooperation with chi ropractors, has turned out to be of great benefit to chiropractor, physician, and patient, and was of great assistance in teaching and in research. When chiropractor and physician work together, almost in symbiosis, the result is something of far greater power than the sum of the two working alone. An analogy can be helpful. The power resulting from fusion of interests on the mental and spiritual plane is akin to that released by the fusion of hydrogen atoms on the physical. Sometimes the chiropractor takes the lead and sometimes it is the physician. Each should learn fTom the other. The chiropractor can help the physi cian by making treatment simpler and more cost effective. Quick, almost immediate, intervention by the physician m akes things better for both patient and chiropractor if something suddenly goes wrong in the management of a disk herniation or spinal stenosis, or sudden development of cauda equina syndrome.

The Fitness Center Even small North American cities have one or two fit ness centers, and large cities have many. This type of venture is usually run by a trained therapist or exer cise physiologist. These centers were started for the benefit of those engaged in athletic activities of all kinds, to both promote fitness and help the resolution of minor musculoskeletal injuries. The client attends at his or her own volition, does his or her own work out, and asks for help and advice as necessary. Many providers of health care use the fitness center to sup plement what they can do for the patient in their office and what the patient can do at home. They refer the patient to the therapist in charge, being careful to let the latter know by phone or written note the nature of the problem, with perhaps some sugges tions as to the type of exercise likely to be useful. The therapist has fTee rein to direct and advise the patient and to control his or her activity. While the patient is attending a fitness center, the health care practitioner and therapist can have fTe quent discussions about the progress made. The chiropractor or physician sees the patient at regular intervals. Sometimes, the professional personally attends the same fitness center, which provides additional valuable contact with both patient and demonstrates that the doctor does the things that he or she advises patients to do. Every chiropractic or medical o ffice should have access to such a sup portive program. Coulehan outlined the dimensions of treatment outcome (7). The doctor-patient interaction is ex pressed in three ways:

(1) focal, the treatment

method; (2) symbolic, resulting from both cognitive and affective influences; and (3) behavioral, again from these two influences. The routine of the fitness center affords all three. It provides the incentive to develop both the physical and the spiritual well being of the client.

Education The back school or self-care program is an essential

The Spandex Bodysuit

part of this. The reader is referred to Chapters 14 and 31. The physician or chiropractor should be able to

prevention and treatment of low back pain is similar

send a patient at any time with delay of no more than

to that put forward by athletes engaged in many dif

2 or 3 days. A back school m ay be staffed by physical

ferent kinds of sporting activities: downhill and cross

The rationale for wearing an elastic bodysuit for the

and/or occupational therapists, sometimes with vol

country skiing: bobsledding; rowing; water skiing;

unteer help, or by two or three chiropractors. It may

and scuba diving, among other things. Elastic trunks

be in the office of a chiropractor, physical therapist,

or suits are often worn by football, tennis, and bas

or physician, or in a gymnasium or hospital outpa

ketball players and by cyclists. Weight lifters wear a

tient department. In many instances the knowledge

similar garment. This type of garment supports trunks


--

895

and pelvis (focal), gives confidence and endurance

They lend credence to any discussion of spiritual fac

(behavioral), and expresses the idea that the athlete is

tors in healing.

a combination of body, mind, and spirit, all working in harmony (8). Physicians, chiropractors, and others have been slow to grasp the fact that an elastic bodysuit is not a rigid corset but something that enhances activity exactly as this type of garment does for the athlete. We need to rethink this means of making extra pro vision for prevention and treatment. In the context o f

Religion and Healing Abdul Baha writes, "Religion and Science are the two wings on which man's intelligence can soar to the heights. It is not possible to fly with one wing alone. With the wing of religion alone an individual would fall into the quagmire of superstition. With the wing

doctor-patient interaction, i t is the symbolic aspect

of science alone he or she would fall into the despair

that is the most important.

ing slough of materialism" (9). Edison patented 1,093 inventions and turned the

Spiritual Factors in Healing A series of steps lead upward from what might be considered the purely physical (if such a state existed) to the completely spiritual (something not seen in this world). In our work as health care practitioners, we are concerned with the spectrum that lies between these two extremes.

inventions of others into a success. For example, in

1879, after many unsuccessful attempts, he made the first electric light bulb. Later on his team produced latex from goldenrod after examining hundreds o f plants. When asked where his ideas came fTom, he used to smile and point to the sky. Quite ordinary men and women like us believe in the existence of a God who is all-powerful and pre pared under certain conditions to intervene in our affairs, provided this intervention does not compro

Help From New Scientific Advances Recent information on the Internet lends support

mise our free will. We seek this help through what we call "prayer." It is wise to do this more o ften than we do.

to the thought that the membrane between this universe and the cosmos beyond is a thin and ten uous one. Scientific investigators of repute believe

Either/Or: BothlAnd

that there is much sound evidence to support the

Something is lacking in the way we think. Perhaps it

existence of an "Intelligent Designer" behind the origin and development of the universe. Darwin does not any longer have it all his own way. Natural selection through the inheritance of acquired char acteristics alone does not give an adequate expla nation of the origin of species or the arrival o f homo sapiens on the scene. These writers s a y that

has always been that way. In most situations, we think in terms of either/or. The chiropractor or osteo path thinks in terms of manual therapy; the physi cian thinks in terms of medication or surgery. In Saskatoon, the process of chiropractors and ortho pedic surgeons learning to work together was at first painful for both sides. Out of this effort came a

it is far more difficult to postulate that the evolu

"both/and" approach, resulting in a synthesis of both

tion of the universe and of life on our planet had

disciplines, something new for us, to the benefit o f

natural causes, taking place "out of the blue," than

both ourselves and our patients.

to believe in the existence of an Intelligent Designer

Turning to consideration of the physical and the

who planned and initiated the whole process. They

spiritual, we encounter the same difficulty. Many

have described in some detail the ways in which the

spiritually minded health care professionals see no

known forces (such as gravity and electromagne

need for anything other than physical and material

tism) and constants (such as the speed of light)

methods of treatment. Priests and ministers who

operate in our universe, interact, and are dependent

have a concern for healing often tend to think in spir

on one another.

itual terms only. The best approach is a synthesis o f

Those who look for further details are referred to two articles on the Internet:

the two. Intermediate steps on the journey fTom the physical to the spiritual contain elements of both and are mentioned only briefly.

1. The Intelligent Design Movement by William

A. Dembski http://www.origins.org/offices/ dembski/docs/bd-idesign.html

Chaos Theory, Nudges, and Ripples

2. The Designed Just So Universe by Walter L.

Chaos theory teaches us that in many situations with

Bradley, PhD http://www.origins.org/offices/

minor changes at the beginning of a particular situ

brad\ey/docs/universe.html

ation we encounter major changes as we reach the

896

--


end. Here for convenience we refer to the factors that

and meetings dealing with the psychologic and im

promote health as "nudges" and those that prevent

munologic aspects of both wellness and disease.

health as "ripples." These factors are pertinent in nearly every human situation. The contrasting two types of factor, ripples and nudges are listed in the box below.

Publications Siegel wrote of lessons learned about self-healing from a surgeons experience with exceptional patients

(12). His approach combines orthodox medicine with

Nudges and Ripples

the spiritual. The American Cancer Society has produced a pamphlet entitled "Say It With the Heart"

Ripples

Nudges

Fear

Listening

Anxiety

Laughter

Anger

Explaining

Matthews-Simonton, and Creighton appeals equally

Uncertainty

Encouraging

to health care professionals and patients with cancer

Boredom

Attention

Hurry

Prayer

to help those with cancer. It is full of helpful sugges tions and emphasizes the importance of the patient's attitude and feelings. Another book by Simonton,

(13). The underlying philosophy is that we are all responsible for our own health and illnesses, and that we participate, consciously or unconsciously, in cre ating our own physical, emotional, and spiritual

Other Resources The back school or self-management program, al ready mentioned, deals not only with material facts but also with the interaction of instructors and

health. The knowledge gained from reading this book can also be applied to the management of many other conditions, be they physical, emotional, and/or spiri tual ("Getting Well Again" is also available on video cassette).

clients and with the whole group in the class. Dis cussion of their problems during breaks is as impor tant as any instruction given. Meditation, relaxation, and imagery can be a part of self-management

The Power of Prayer Many of us believe that the natural indwelling defenses

they can be taught individu

against foreign invaders and disease, including the

ally, both with great benefit. An integral part of this

immune system, were given to us by God as part of

process is how to manage stress. This subject is dis

our make-up; that our environment contains many

or

cussed at length by Zahourek (10). To use the imagination is most helpful. Sanford

resources for healing, substances like penicillin and digitalis; and that health care professionals and others

(11) tells how she was able to help a small boy with a

have their source of training directly fTom Him-it is

serious heart condition. She discovered that he was

no accident that hospitals and clinics had their otigin

fascinated by football. She said, "Let's play a game."

in the monasteries of the Middle Ages.

He nodded and agreed. "Billy, imagine that you are

It is not too great a stretch of the imagination to

playing football and that you are getting better and

believe in the existence of an all-powerful being, pre

better at it. One day your team is playing against the

pared under certain circumstances to intervene in

best team in the league. You play so well that you

our affairs. Again, we seek this help through prayer.

score more goals than anyone else and win the game

It is easy to ignore the existence of a power greater

for you r side. You hear some of the onlookers say

than ourselves when the sun is shining. Then oLlr god

'Just look at Billy, how fast he can run, how well he

may well be golf, our savior the computer, our inspi

tackles, how strongly he kicks the ball. We'd like to

ration gained from thoughts of sex. When ill health

be like him. He must be so fit and well.' Billy was

and disaster loom ahead, we are more inclined to

thrilled." Sanford continues, "Can you make a pic

look above and beyond ourselves for help. Fortunate

ture of that in your mind three or four times every

is the man or woman, health care professional, or

day." Once again, Billy nodded vigorously. He did

patient who seeks to take advantage both of the nat

this every day. After a few months, he became per

ural provisions for health and wellness and of those

fectly fit and welJ again, with no problem with his

from the supernatural realm.

heart. He later became a great football player.

The same sort of interaction can take place when

The Institute for the Advancement of Human

someone has severe low back pain at a time when

Behavior, another resource, is situated in Stamford,

both patient and doctor are at their wit's end. A priest

Connecticut. This organization of psychologists, psy

in the Episcopal Church developed severe back and

chiatrists, and other practitioners plans seminars

leg pain of sudden onset. He contacted a fTiend who


in turn called his friend, an orthopedic surgeon. The

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897

that are di fferent [Tom o u r own. It is good to be

surgeon examined the man and thought he had an

aware of the presence and involvement of the Cre

acute L4-S disk herniation. This suspicion was con

ator in any and every scenario in which client and

fi rmed by a CT scan. Members of the priest's church

helper seek health and wholeness. This statement

prayed ror him that night. On his next visit, the sur

does not imply that we are a l ways talking about

geon prayed for him as well, with sorne reluctance

such awareness. When we ourse l ves do not have

(surgeons do not usually pray for priests ! ). In the

access to this kind of help, we should feel free to

middle or that night, the patient woke up and real

refer the client to someone else who has. The One

ized all his pain had gone. From that point, he had a

who sits on the throne is able to come "alongside"

rapid and uneventful recovery. The priest l ater said

us just as we are taught to come alongside our

that he had experienced two miracles: the first was that

clients in their need.

a surgeon had visited him in his own home, and the second was the healing of his back. Audit Process

Self-Check of the Chapter's Learning Objectives • CO N C LUSION Interaction between physician, chiropractor, and

• •

patient is both rundamental and complex. The result •

alone. The raw materials of which they are built come from a variety or sources: •

A careful s tudy of science and its branches

•

The humanities

•

Philosophy

•

Myth, the story with a meaning

•

Behavior, symbol, and metaphor

The combinations of these sources with the greatest significance are those with a s trong symbolic con

•

or an individual's reaction to a situation of life and

What are some resources that can help the patient maintain spiritual balance?

• REFERENCES 1.

M acmurry J . Reason and Emotion. London: Faber and Fabel-, 1 93 5 .

2.

M acmuny J . Creative Society. London: Faber and

3.

Blanchard K . L i stening: a Basic Business Skill.

Fabel-, 1 93 5 . I nside Guide, Newsletter for Canadian Plus. Toronto: Grant N. R. Geall; June, July, and August, 1 992 .

ror one another. The search may involve us in efforts from sl ight difrerences in dress to grasping the nature

W hat are some good ways to gain a patient's trust or confidence?

tent. Good relations stem from our seeking the best to understand aspects of a persons psyche that range

How does good or bad listening skill i mpact patient satisfaction?

ing relationships are the phenomena of most impor tance. They depend on something more than science

What are patient's expecting on the first visit?

4.

Dixon T. The philosophies of family medicine (edi torial) Can Fam Physician 1 98 9 ; 3 5 : 74 3 .

death. At times, it is not difficult [or the discerning

5 . Chapman-Smith D . Renections o n the H awthorne effect. Chi l-opracti c Report ( editorial ) . 1 989;4: I .

physician to empathize with the distress felt by a

6.

patient, sharing the symbolic content and the behav ioral aspects of the situation. The practitioner must shi ft from time to time from c lose identity on the stage to standing back in the wings. In the process of traveling with a client from a state or distress to one of complete well-being, we should be prepared to seek help fTom other sources. Complete rapport between the physician and the chi ropractor is or greatest significance and also is rewarding. The convergence of ideas and beliefs held by students and teachers rrom two different back grounds produces within them the stimulation re quired to conquer new areas in the spectrum of musculoskeletal illness. Given the l arge a number o f different approaches to spiritual healing, it is essential to respect beliefs

Dixon T. In praise o f the Hawthorne Effect (editorial ) . Can Fam Physician 1 989;35:703.

7 . Coulehan L . The treatment act: An analysis o f the clinical art in chiropractic. J Manipulative Physiol Ther 1 990; 1 4 : l . 8 . Kirkaldy-Willis W H o Energy stored for aclion: The elastic bodysuit . In: Kil-kaldy-Willis W H , Burton CV, eds. Managing Low Back Pain. New York: Churchill Livingstone, 1 99 2 . 9 . Abdul B . Paris talks. London: Bahai Public Trust , 1 9 7 3 : 1 43 . 1 0 . Zahourek R . Relaxation and I magery. Philadelphia: WB Saunders, 1 98 8 . 1 1 . Sanford A. The Healing Light. N e w York: Ballantine Books, 1 98 3 . 1 2 . Siegel BS. Love, Medicine and M iracles. N ew York: Harper & Row, 1 98 6 . 1 3 . Simonton OC, M atthews S , Creighton J L. Getting Well Again. New York : Bantam Books, 1 9 80.

The Role and Safety of Activity in the Elderly

Craig Liebenson

Introduction

Frailty

Cardiovascular Risks and Benefits Cardiovascular Benefits Associated With Activity and Exercise in the Elderly Cardiovascular Risks Associated With Activity and Exercise in the Elderly

The Problem Interventions

Spinal Stenosis Diagnosis Potential Complications

Osteoporosis

Results

Risk Factors Role of Exercise

Exertional Risk Assessment ACSM and AHA Risk Assessment Recommendations

Knee Osteoarthritis Function

Limitations of ACSM and AHA Risk Assessment Recommendations

Rehabilitation

Total Knee Arthroplasty

Gill's Recommendations for Screening Elderly Individuals for Cardiac Risk With Exertional Activities

Demographics Recovery Expectations Rehabilitation

Recommendations for Initiating and Progressing Mild to Moderate Exercise Programs in the Elderly

Hip Osteoarthritis Function Exercise

Total Hip Replacement Recovery Expectations

Learning Objectives

After reading this chapter you should be able 10: •

Rehabilitation

Fall Prevention The Problem Associated Functional Deficits Interventions

898

•

Unders land how activily in l he elderly is assoc i ated w i l h all causes morlal i ty Understand how acli vi ty in lhe elderly can be better promo led by heal lh care providers

Chapter Thirty-Seven: The Role and Safety of Activity in the Elderly

•

•

•

Screen for risk factors wi l h exerli on in the elderly Organize rehabi l i lation services for patients with oSleoarthri l i s , osleoporosi s , j o i n l arlhroplasty, and spi nal s lenosis O ffer oSleoporosi s , balance and frai l ly preven tion services

Introduction Heal lhy l i festyles i ncorporating physical activity and exercise have been shown to be highly beneficial for persons aged 75 and older. Reduclions in functional dec l ine ( frailly), coronary hearl d isease (CHD) , and disabi l i lY before death along w i l h i ncreased l i fe ex peclancy have al l been demonslraled ( 3 1 ,48,72 , 1 1 3 ) . Specific exercise programs have also been shown l o prevenl fal ls i n the elderly (42, 1 34 , 1 3 5 ) a n d i mprove [unclion and quality of l i fe in i ndividuals with oSleoarlhritis (44,97, 1 2 1 , 1 2 8 ) . A recenl Surgeon General's report i ndicates that only 22% o f adu l ls in the Uni ted States are act ive enough lo derive benefits [Tom aClivity ( 1 00 ) . Mean w h i l e , The American College o f Sports Med i c i ne and the Cenlers for Disease Con lrol and Preven tion ( C DC) recommend that all Americans should engage in a m i n i m u m of 30 m i n u les of moderate physical acti v i ly daily ( 9 5 ) . The Nal i onal I n stilule of Health ( N I H ) also i ssued sim i lar recom mendations ( 1 0 1 ) . I n a landmark reporl , the Surgeon General of the Uni led Stales slaled that o l der people regardl ess o f gender or socioeconom i c class are not exerc i s i ng as much as lhey shoul d , with women generally less aClive lhan men; 30% o f women ages 60 l o 69 engage in no leisure l i m e aCl ivi lY compared with 1 7% o f men ( 1 00 ) . I n 80-year-olds, 6 2 % o f women a n d 40% of men engage in no l e i sure l i me aCl ivity. The Sur geon General cal l s for alleasl 30 m i n u tes of physical activilY per day. Exerc i se has even been shown to be related t o i ncreased l i fe expeclancy. I nactive m e n 6 0 years of age who become active have a morta l i lY rale 50% lower lhan lheir peers who remain i nactive ( 1 1) . A study of Harvard University alumni confirmed this result. Men who were i n i l ially sedenlary bUl later began engag i ng in vigorous sports had a 23% lower rale of mortali ty t han lheir i nactive counterparts ( 92 ) . A Honolul u Hearl program found t hal rel i red m e n w h o walked more l han 2 m i les per day had half the mortality rate (22%) l han t hose who walked less than 1 mile per day (43%) (47 ) . A fol low-up study by Hakim reported that men who walked less than 0 . 2 5 m iles per day had a 2-fold i ncreased risk of coronary heart disease than those who walked 1 . 5 m i les per day. Also, men who walked more l han 1 .5 m iles per day experienced even

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899

greater preve n tive benefit. Women nurses have also been shown to reduce their risk o f cardiovascu lar d i s ease fTo m walk i ng (48). Many physicians counsel patienls abo u l smoking and body weight, but not abou l i naclivily ( 1 8 ) . In lhe past il was beli eved that u nless exercise i n lensily was fai rly high (600/0-80% max i mal heart rale) thal health benefits would not accrue. A 3- to 4-mph wal k i s now acknowledged as beneficial (4). Additional ly, exercise does not have to be al one time; l here fore, for instance three 1 O-mi nute walks w i l l be of benefil ( 3 3 ) . The faclors that l i m i t physical performance i n lhe elderly are ei ther immutable or modifiable. Immutable characteristics include such thi ngs as gender, race, age, or chronic health problems. M od i fiable i nclude behavioral ( i. e . , moderate exercise), social nelwork c haracteristics, and psychol ogical characleristics ( i . e . , self-efii cacy beliefs) (see chapter 1 4) ( 1 1 3 ) . Bolh physical exercise and emotional supporl from one's social nelwork predict physical performance over a 2 . 5 -year follow-up period (I 1 3 ) . In fact, moderale activities (leisure walk ing) are as e ffecl ive as strenuous activities (brisk walking).

Cardiovascular Risks and Benefits Cardiovascular Benefits Associated With Activity and Exercise in the Elderly

The Cochrane Col labertation reviewed randomized, contro lled trials and foun d l here was a 27% reduction i n all-causes mortality in lhe exercise-only i n lerven tion groups (odds rati o , 0.73; 95% confidence i n lerval [Cl], 0.54-0 . 9 8 ) . Total cardiac m orlal i lY was reduced by 3 1 % (odds ratio, 0.69; 95% CI, 0 . 5 1 -0.94)( 5 5 ) . The E u ropean Society of Cardiology has provided age spec i fic recommendations for exercise ( 3 5 ) . Regular activity decreases l he risk o f MI and dealh, and l ow cardiovascular (CV) fi tness if measured as endurance is well-corre lated wilh C H D and morlal i ty (69 , 1 32 ) . This may be lhe mOSl i m portant s i ngle i ndependent risk factor. Agi ng and decreased CV fil ness as measured by m ax i mal oxygen consu mption (V02max) are d i rectly associated. In a long-term ( 1 6-year) fol low-u p study, The M u l tip l e R i s k Factor I n tervention Trial s ludy found l hal a m oderate exercise program reduced mortali ty from heart d isease ( 7 1 ) . The study popu lation incl uded men at relatively high risk for C H D caused by being sedentary. Data showed that a relati vely small amount ( 1 0-36 minu tes per day) o f moderale i n len sity l e isure t i me exercise reduced premature morlal i ty from C H D . The intensi ly of physical activity relative to effort and card iovascular fi t ness m ay also be relevant ( 7 0 ) .

900

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Cardiovascular Risks Associated With Activity and Exercise in the Elderly

Wi th such c lear benefits o f physical activity and exer cise among older persons, i ssues of the safety and risks o f re-activati o n in t h e elderly or heal t h com prom ised need to be detail e d . O nl y when the risks and benefi ts are explai ned clearly can a c hange i n beh avior be expected ( see Chapter 1 4) . T h e Myocardial I n farc t i o n O nset S t udy was per formed to identi fy activi t i es that trigger an acute myocard ial i n farction ( M!) in e l derly i n d i vi duals. The re l ative ri s k o f M I in t h e hour after vigorous physi cal exertion was 1 2 .7 ( relative risk is the rati o o f i nc i dence rates for a condi t io n i n t w o distinct popu l a t i ons-in t h i s case for MI after vigorous exer t i on versus normal acti v i t y ) . Vigorous physical exert ion is equivalent to six metabol i c equ ivale n t s ( M ET S ) , w h i c h i n clude s l ow j ogging, speed wal king, ten n i s , heavy gardening, and s hovel i ng snow. The relative risk o f M I w i t h i n 2 h ours o f sexual i nter course ( 3-4 M ETS) was 2 . 5 ( 81 , 8 4 ) . The Card i ovascu lar Health S t u dy-the o n l y pop ulati on-based , long i t u d i nal study of cardi ovascul ar di seases in older i nd ividua ls-reported that regular vigorous exercise 3 days per week increased the risk o f MI from 1 . 3 % to 1 .6% in a 79-year-old woman , and from 3 . 9% to 4 . 8 % i n a 90-year-old man. How ever, over Li me the risk would fal l because those who exercise regularly have a l ower rel a t i ve risk that an M I w i l l be triggered by heavy p hysical exert i o n (43 , 8 1 ) . I n fac t , regular activity or exerc ise h a s been shown to red uce the risk of M I and death in older adults (47, 4 8 ) .

Role of Exercise

Ideal exercises are weight-beari ng. Examples i nclude walking, h iking, jogging, stair c l i mbi ng, ten nis, and dancing. Although more recen t studies suggest h igh i n tensity exercise can i ncrease or mai ntain bone den s i ty i n premenopausal women ( 8 ) as well as elderly men (73 ) . lL h a s been shown that certai n exercises are more risky than o t hers. Postmenopausal women w i t h low spine bone m i neral density have a greater incidence of further wedge or compression fractures if they perform trun k flexion rat her than tru n k extensi on exercises ( 1 1 0, 1 1 6) .

The Young Female Athlete and Osteoporosis Young women partici pating i n high-intensity exer cise ( i .e . , runners, triathletes, ballet dancers) are vul nerable to n umerous adverse effects s i m ilar to elderly women 1.

Reduction i n estrogen leve l s s i m i lar to post m enopausal state

2. Menstrual abnormal i t i es

Present i n 50% of compet i t ive female athletes versus 5% of normal populati on ( 1 6) • Ol igomenorrhea ( i rregular menstrual cycles) • Amenorrhea (cessa t ion o f menstrual funct i o n ) 3 . Osteoporosis •

•

•

Osteoporosis Risk Factors

Loss o f bone mass occurs with agi n g . This leads to bone fragi l i ty and an i ncreased i nc i d e nce of frac ture, espec ially to the h i p , spine, and wrist. The i nc i dence varies wi t h s e x , geography, a n d e t h n i c i ty. T h e post menopausal w hi te female i s at part i cular risk. Regional variations ex ist, with American women in the southeast bei ng at h ighest risk (99). The l i fe t i m e i nc i dence o f a h i p fracture i n a 50-year-old wh ite American female i s 1 7%, w hereas for a s i m ilar w h i te male it is just 6% ( 2 4 ) . S t rong ev idence has accum ulated t h at physical act ivity (aerobic and progressive strengt he n i ng) helps mai ntain bone mass in premenopausal and signifi can t l y s lows bone loss i n pos tmenopausal women ( 1 3 0 ) . The effect was approxi m ately 1 % per year favori ng exercisers as seen by decreased rates of bone loss in the lu mbar spine and femoral neck ( 1 30).

•

Despite high levels of physical activity bone loss is common particu l arly in the lu mbar spine (27, 1 09 ) Increased r i s k o f stress fractures (86) Increased risk o f osteoporosis later i n l i fe

Knee Osteoarthritis Function

Patients with knee osteoart h ri t i s have a lower wal king speed, shorter stride, reduced ankle power at terminal stance, and dysfu n c t i onal kn ee k i n ematics when wal k i ng at a paced speed (78 ) . They h ave i ncreased muscle activity and m uscle co-activation during gait and stair descent o n a 20-cm step (21). It has been sug gested that t h is step height may be too high [or the elderly ( 2 1 ). Poor balance has been found in individu als with bilateral knee osteoarthritis more so than in an age-matched con trol group ( 1 31). Pandya et al. reported that knee OA reduces obstacle avoidance strategies and i ncreased the propensity to trip on an obstacle (the greater the pain the greater the risk) (93) Activi ty levels and funct ional performance (sel f paced walk test, t i med up-and-go test, and timed stair


performance) measures i n i ndividuals awa i ting total knee arthroplasty (TKA) are much lower than i n fi t elderly ( 1 24). O A patients had the following disabili ties com pared to age-matched non-sufferers ( 1 24 ) . • •

•

Household score o n l y 1 6% compromised OA patients c l i mbed fewer stairs, shopped less o ften OA patients sports part icipation was 1 0% of asymptomatics

OA patients w a l ked at a 62% slower pace. Female patients had 46% the m uscle e ndurance. O f note is the fact that the performance tests were n o t more painful in the symptomatic group.

Rehabilitation

OA orten leads to sedentarism and thus can i ncrease the risk of CVD, yet historically pati e n ts w i t h OA were advised to avoi d activity ( 1 2 , 1 00 ) . It is now rec ognized that exerc ise programs for patients w i t h knee o r h i p OA are beneficial (7,2 2 , 2 8 , 1 00 ) . I n a large study of 439 i nd ividuals older than the age of 60 w i th radiologic knee OA, e ither aerobi c or resi stance exer c i se improved f-unct i on and reduced pain w ithout i ncreasing any signs of radi ograph i c arthrit i s ( 2 8 ) . Petrella reported that i ncreases i n physical capacity and physical activity are achieved with exercise ( 97) . Such rehabil i tation may be preventive of end-stage OA requ i ring total k nee art h roplasty ( TKA) . Speci fic approaches found to be effective i nclude: •

Isometric quadriceps tra i n i n g (44,97, 89)

•

Supervised walk i ng ( 1 27)

•

General aerobic conditioning ( 96, 1 28 )

Patients whose self-efficacy i m proves w i t h treatment experienced the greatest improvement ( 5 9 ,60, 1 2 8 ) . The combi nation o f psycho-soci al approaches w i t h exercise was superior t o e i ther alone. Keefe recently reported that spouse assisted coping skills tra i ni ng enhances the effectiveness of the treatment p rogram [or knee OA (6 1 ) .

Demographics

Joi n t replacements of the h i p and knee are typically performed on i ndividuals between 65 and 80 years old ( 94) . Joint replacement surgery is now being per formed on i nd ividuals as young as 40 or as old as 90. I nd ividuals i n their 40s and 50s have more rap i d aseptic loose n i ng h'om polyethylene wear. Survivor s h i p of the i m plants is better i n women than men.

90/

Recovery Expectations

Pain relief usually begins 1 week postoperatively ( 54 ) . R issanen reported a 55% reduction i n p a i n i ntensi ty at 2 and 5 years ( 1 04 ) . Noble recently reported TKA patients continue to experience s ignHicant d isab i l i ty compared to t h eir age and gender matched peers. Table 37. 1 summarizes the major areas where d i ffi culty can be expected Shai reported that after TKA all patients could kneel u n der supervision, but, their perceived ability to kneel was less than their observed abil i ty ( 1 1 1 ) . Those who had d i fficulty kneeli ng had scar pai n or back related problems as major factors l i m i ti ng kneeling abi lity. Noble also reported that TKA patients had s i m ilar function as their asymptomat i c peers with swimm i ng, stationary bik ing, and golfing ( 8 8 ) . Kinemati c a n d electromyographic assessment o f function during t h e timed u p and g o test, 6-meter walk , and stair ascent revealed a n umber of pre TKA deficits, which all persisted postsurgically (90). Specific impairments that were i dentified include i ncreased h i p mobility and decreased knee and ankle mobility. More intensive postsurgical rehabili tation was recommended to address these functional defici ts.

Rehabilitation

M u n i n found that early rehabilitation ( day 3 ) was superior to a usual care group ( 8 5 ) . The rehabil i tation group had a shorter duration hospi ta l stay, lower total cost of care, and more rapid atta i n ment of fu nc t ional goals.

Hip Osteoarthritis Function

Patients with h i p OA typically have a number o f func t ional deficits. Reduced h i p strength compared to

Table 37.1

Expected R esidual Functional Defi c i ts

After TKA •

Total Knee Arthroplasty

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• • • • • • • • • •

Knee l i ng Squatting M ov i n g l a terally Turni ng and c u t t i ng Carrying loads Stre tching Leg strengtheni ng Tenn i s Dancing Garde n i ng Sexual activity

902

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Table 37.2 •

• •

Residual Functional Deficits After T H R

Doublestance t i m e d uring gait i s significantly l onger compared to normal Gait vel oc i ty i s s lower There i s a s light lean toward the operated l i mb t h roughout t h e doublestance phase

age-matched controls and marked m uscle atrophy compared to the contralateral hip ( 5 ) . Those with end stage OA have severe CV decondi ti o n i ng ( 9 8 ) , and altered gai t pattern in i n d ividuals (65 ) . Poorer physi cal and social functioning has been documented i n those await i ng total h i p replacement (THR ) compared to population norms (62 ) . Patients wi t h end stage h i p O A were fou n d t o have decreased h i p m uscle strength compared to age and gender matched peers: 5 1 % for thigh extensors and 68% for thigh flexors ( 3 7 ) .

Exercise

An 8-week exerc ise program w i t h strength t ra i n ing and l i festyle advice for o l der adu l ts ( o l der than 5 5 years) w i t h hip OA was studi e d ( 1 2 1 ) . The pro gram had a pos i t i ve e ffect on pain , h i p function, self-reported d isabi l i ty , and performance ( t i med u p and-go tes t ) . General aerobic tra i ning h as also been found to be beneficial ( 1 2 8 ) .

Medicare data suggest that 5 2 % of h i p replace ment and 77% of revisions are performed by surgeons who do fewer than 1 0 procedures per year (56-58). S i m i lar data exist for hospitals. Morbidity and mor tal i ty data show an i nverse relations h i p to hospital procedure volume. Patients felt they were ready for di scharge fol l ow ing T H R if they felt safe (50). This was related to their confidence and the support o f fami ly and fTiends.

Rehabilitation

Berge fou n d t h at t h a t non-rehabi l i t ion pati ents had a 43% reduction in pain i n tensity, whereas rehab i l i ta t i o n pat ients experienced a 5 5% decrease ( 1 0 ) . Fu n c t i o n was not benefi ted, bu t qua l i ty o f l i fe w a s . T a b l e 3 7 . 3 s u m marizes a pre-habil i tation program that demonstrated pro m i s i n g e ffec t i ve ness ( 3 7 ) . Maire h as shown t hat a n upper extrem ity exercise program is effect i ve i n postsurgical rehabi l i tation for T H R ( 7 5 ). Passive physical t herapy a fter T H R has been shown t o l ead to deterioration o f bot h exercise capac i ty and physical condition . The upper extrem i ty exerc i se program starts 1 week postoperat ively. It i nvolves 3 0 m i n utes per session at a fTequency of three t i m es per week for a duration o f 6 weeks. Each session consists of: •

6 consecutive periods of 5 min utes

•

4 m i n u tes of low- i ntensi ty "base" work o

Total Hip Replacement Recovery Expectations

Pai n rel ief usual l y begins 1 week postoperat ively ( 5 4 ) . I m provement is wel l -estab l ished by 3 months (68 ) . Rissanen reported a 55% red u c t i on i n pain intensity at 2 and 5 years ( 1 04 ) . Patients and surgeons have d i fferent expectations and define success and fai l u re based on d ifferent cri teria ( 1 4 , 1 5 ,94). Surgeons define fail u re as need for revision w h i l e patients define fai lure as persistant pain t hat l i m i ts function. Preoperative expectation o f pain reduction exceeds what i s achi eved ( 2 6 ) . Patient's satisfaction w i t h surgery depends more o n preoperative expectations regardi ng symptom rel ief and return o f function ( 7 4 ) . If the patien t's cri teria for surgical fai l u re ( sa t isfacti on) is used as a criteria for success, then 2 0% of THRs fail, whereas if surgeon's criteria of revision is used then only 7% fail (94). Suc cess with TH R is usual l y based on revision rates or a scori ng system includ i ng assessments of pain, wal k ing abil ity, j o i nt mobi lity, and radiologic fi nd i ngs ( 3 0 , 3 2 ) . Residual fu nctional deficits are summarized in Table 3 7 . 2 (1 J 7 ) .

•

Venti latory th reshold

1 m i nute of i n tense "peak" work o

Maxim u m tolerated power

The Best Outcomes W i t h Su rgery Occur i n Patient Who Partici pate i n Preoperative Rehabi l i tation

Table 37.3

- F i t , strong patients rehabil itate more quickly after surgery than those less fit - 4.2 days in hospital vs 7.2 days for prerehabi l i tation vs non-prerehabil i tation patients - Preoperative hip strength was an independent pre dictor of length of hospital stay - 30-minute aerobi c and strength program fol l owed by 30-minu te mobil i ty and gait in hydrotherapy pool program - Start w i t h 5-minu te warm-up on cycle - Con trol subjects at 24 weeks postoperat ively had more d i sabi l i ty than prerehab i l i tation patients at 1 2 weeks.


Clinical Pearl Key Activity Modifications to PROTECT an Artificial Hip •

Avoid nexion past 90°

•

Avoid addu ction past neutra l

•

Avoid h i p int ernal rotation

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903

the body weight up. The extension moment in knee is doubled in stair c limbi ng versus level walki ng; 1 1 weeks of eccentric leg m uscle train i ng i n elderly indi viduals at high risk improved stair descent perfor mance by 2 1 %, balance by 7%, strength by 60%, and significantly decreased the ri sk of fall i ng (67).

Interventions

Fall Prevention The Problem

Few areas of med icine are more i m portan t than reducing the burden o f hea l t h care problems i n the elderly. In Canada, nearly one-third of al l seniors will fall t h i s year ( 1 2 3 ) . Fal l s are responsible for nearly 40% of the Can ada's senior health care costs! The Cal i fornia Department o f Agi ng i n t h e Department o f Hea l th Services h a s created a N o M o re Falls! Pro gram. The sel f-care advice i s responsible for a 20% reduction in fal l s 1 year after completion of program ( 1 05 , 1 06). Publ ic heal t h organizations such as t h e Rand Corporation a n d Coch rane Collaboration have mobi l ized recently to address t h i s preven table healt h care di lemma ( 2 ,20,42, 1 08 , 1 1 2 ) . A study of Australians found that one-t h i rd of fall ers are mul tiple fal l ers ( 8 3 ) . M ost of these are e lderly women with co-morbidi ties, perceived di fficulty walk i ng, poor sel f-rated eyesight, and back pai n .

Associated Functional Deficits

A number of f'u nctional deficits (impairments) have been shown to increase the i n c i dence o f fal l s . De creased si ngle l eg standing balance time (less than 30 seconds) has been shown to correlate with a h is tory of fal l i ng, whereas a l onger balance time sug gests a much lower risk ( 5 3 ) . Pandya et al. reported thal knee OA reduces obstacl e avoidance strategies and increased the prope nsity to trip on an obstacle ( t he greater the pai n the greater the risk) ( 9 3 ) . Reduced peak h i p extension mobil i ty and increased anterior pelvic t i l t distinguishes elderly fallers from young adu l ts (63 ) . Knee l i ng h i p extension stretching was l ater shown to i m prove hip extension mobility and ankle plan tarflexion mobi l i ty and power genera tion (64 ) . Fal ls o n stair descent outnumber ascent 3 : 1 (67). Eccentric contraction i s u t i lized. Nadeau has studied the task of stair cli mbing ( 87). It requires concentric action of h i p abductor muscles. Elevation of the con tralateral hip is necessary for the swi ng phase leg to avoid the step. It is important to assess this. Decreased knee flexion is also a problem with stair climbing. Strength of the knee extensors i s needed also to raise

An i n terve n tion i nc l u d i n g exercise was superior to one w i thout exerci se in reducing the i nc i dence o f fall s . When balance trai n i ng w a s added t h e e ffective ness was even greater ( 1 03 ) . Brandt et al. have found that elderly with ataxia can be treated successfully w i th balance trai n i ng ( 1 3 ) . Two weeks of train i ng was shown to lead to significant improvement 9 months later without any home main tenance program . Thick foam is used on the floor to deplive the feet of sensory feedback and the eyes are closed, t hus fac i l i tating the vestibular and somatosen sory systems. Similarly, you can fac i l i tate optokinetic and mechano receptor ( feet) function by leaving the eyes open , but tipping the head back ( taking the otoliths out of their functioning range) .

Clinical Pearl Home Advice for Fall Prevention •

E l i m i nate loose rugs and wire

•

Ensure handrails on a l l stairs

•

Recom mend use of handrai l especially when goi n g down stairs

•

Practice balance tra i n i ng

•

Increase CV fitness w i t h aerobi c tra i n i n g

•

Increase dyna m i c strength especi a l l y or legs

In another 5-week balance program, only shorter-term results were ach i eved , thus suggesting for mainte nance of results that trai n i ng may need to continue ( 1 1 4) . Two different trials of Tai Chi showed that a longer term program i m proves balance abilities o f older adu l ts a n d t h a t i mprovement persisted after traini ng stopped ( 1 34 , 1 3 5 ) .

Frailty The Problem

Decreases i n muscle strength and mass are an i nevitable consequence of agi ng. A consistent feature of age and i nactivity is l i mb muscle atrophy and the

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loss o f peak force and power ( 1 2 5 , 1 26 ) . H owever, recen t studies show t h a t the rate o[ age-related m us cle l oss-sarcope n i a-can be slowed down w i t h i ncreased activity (aerobic and resistance) and nutri t i on (androgens and growt h hormone) ( 1 07 , 1 2 9 ) . I nsul in resistance h as been shown t o have a possible l i n k to the deve lopment o f sarcopenia ( 1 29 ) . Sacrope n i a is especially risky for o l der i n dividuals facing acute or chro n ic i l l nesses . It i s i mportant t o maxi m ize m uscle mass and p rotein stores to m a in t a i n qual i ty o f l i fe wi t h advanci n g age. H ealth care pro fessionals and the publ ic have focused m uch atten t i on on age-rel ated changes i n bone density, but have ignored t hese muscle c hanges. Yet, muscle changes are extremely i m portan t w hen one consi ders risk o f fa l ls, fractures, a n d general well-bei ng. Consistent w i t h the benefits o f p hysical acti v i ty and exercise are t h e debi l itat i ng effects of prolonged bed rest . McGu i re et a l . showed in 1 966 that i n heal t h y 20-year-old m e n , 2 0 days o f com plete i nac tivi ty led to serious decon d i t i on i ng ( 7 9 ) . An 8-week dyna mic t ra i n i ng program l argely reversed the neg ative effects of bed rest. A recen t follow-up s tudy on this cohort demonstra ted that nearly equivalent amou n ts of decondi t i on i ng as occurred with 2 0 days of bed rest occurred from 30 years of agi ng i n l argely sedentary i n d i vi d u als ( 79)! S i g n i ficant i ncreases in body wei g h t ( 2 5% ) , body fat ( 1 00%), and de creases in max i m u m oxygen consumption (V02max), maxi mal h eart rate, and maxi m a l stroke vol u m e oc cu rred . Aga i n , a condi t i o n i ng program-t h i s t i m e for 6 m o n ths-focu s i ng on endurance reversed the decond i t i o n i ng o f 3 0 years ( 8 0 ) . A few poi n t s e merge fro m t h i s work. F i rs t , t h a t 2 0 days o f bed rest i s as deleterious a s 3 0 years of sedentary l i festyle. Second, decon d i t i o n i n g i s re vers i b l e ! McGuire reported t hat " 1 00% of the age related decl ine in aerobic power . . . was reversed . . . " (80). Physical fra i l ty ( as determi ned b y g a i t speed ) was the o n ly factor that was associated sign i fican t l y wi t h t h e devel opment o f i ns i d i ous d i sabi l i ty (odds rat i o : 2 .4 , 9 5 % confidence i n terva l : 1 . 4 t04 . 1 ) (4 1 ) . A recen t report found that habi tual phys ical activi ty i s a n i n dependent predictor of successful recovery of i n dependen t activities o f d a i l y l iving ( A D L ) [unction ( ba t h i ng, dressing, walki ng i nside t h e house, and transferri ng ['-om a chair) among newly d i sabled com m u n i ty-dwe l l i n g o lder persons (49).

Interventions

G i l l et a l . tested a 6-month home care exercise pro gram for a physically fra i l group of commu nity- living older persons ( 39 ) . Physical fTa i l ty was determ i ned by

two tests shown to be most pred ict ive of fu nctional decli n e ( 1 02 , 1 3 2 ) : •

•

•

Rapid gait (back a n d forth a s fas t a s possible over a 3 -meter course) S i ngle chair stand ( s tanding up from a hard back chair/arms folded ) Score: [Tai l i f more than 1 0 seconds on rapid gai t and unable to do si ngle cha i r stand with arms folded o

Severe-if fai led both tests

o

M oderate-if fai led one test

The program was h ome-based and targeted specific i m pairments in physical capacity. There was an em phasis on adherence by describing the i m pai rment and how t h i s cou l d affect the person's abi l ities. The patient was asked i f t hey agreed and if they wou ld l i ke to work to overcome t h i s i m pai rment. I nterven t i ons were explai ned and the patient asked to rale t h e i r bel ie f i n the chances of success with the inter vention. The patients pre ferences were explici tly i ncorporated i nto the program The control group received only education vs the i nterven tion group's exercise. The exercise group real i zed si gni ficantly greater i m provement in dis abi l i ty, mobili ty , and physical performance at 7- and 1 2-month fol l ow-ups. ADL i m provement was 45% greater a t 7 months and 37% greater at 1 2 months in the exercise versus educat ion group. In a fol l ow-up to t h i s study, G i l l found t here was no i ncrease in adverse events in the exercise group versus the edu cat ion group (40). C h a n d l e r e t al. fou n d that a l ower extre m i ty strengthening program improved mobi l i ty, chai r rise performance, gait speed, and fal l s efficacy in a group of h-ai l comm u n i ty-dwe l l i ng elders ( 1 9 ) . The more impaired the i n dividual the greater the im provement i n strengt h .

Spinal Stenosis Diagnosis

Spinal stenosis is a cl i n ical term not a rad io logic fi n d i ng ( 1 2 0). A narrow canal does not necessarily cause symptoms. Spine problems often restrict activ i ties, for i nstance, i ndividuals w i t h spi nal stenosis h ave reduced wal ki ng tolerances. I nactivi ty i s i tsel f a cardiac risk factor. Neurogenic claudication associ ated w i t h spinal stenosis is the n u mber one sympto m a t i c spine probl e m in t he e l derly and reason for spi ne surgery. In fact, l ow back su rgery for i ndividu als o lder than age 65 i s i ncreasi ng dramatically. Such surgeries are not without risk and card iac com pl ica-


ti ons are recognized as the lead i ng cause of death i n such operations ( 2 9 ) . Leg pain w i t h wal k i ng is t h e h a l l mark o f spinal stenosis and m ust be d i fferentiated from vascu lar claudicat ion. Pai n with walking that is relieved w i t h stooping while wal king i s diagnostic. A patient w i t h stenosis wi l l b e worse o n a tread m i l l t han a bicycl e whereas vascular claudication will n o t . A 2 0-mi nute treadm i l l test on a level surface correlated strongly with spinal stenosis symptoms wit h 88% of pre operative patients having a s i g n i ficant increase o f their sym pto ms ( 1 2 2 ) . I n cont rast only 41% of patients had significant symptoms wit h a 1 0-min u t e bicycle t e s t w h e n hol d i ng h a n d l e bars. O n repeat test i ng 2 years postopera tively there was significant i m provement in the tread m i l l tes t , but not in t h e bicycle test.

Potential Complications

The overa l l com p l ication rate was 40%; h owever, serious com pl ications were l ess com mon, occurri ng in 1 2% o f patients ( 9 ) . Deyo found that if the surgi cal procedure i ncluded arth rodesis patients had an i ncreased risk o f morbidity as wel l as an increased length of hospital stay ( 2 5 ) .

Results

Atlas et a l . has com pared conservative to surgical care fOt-spinal stenosis and found at 8- to 1 0-year fol l ow-up that l ow back pai n relief, predominant symp tom improvement, and satis faction with the current state were si milar in patien ts i niti a l l y treated surgi cal ly or non-sur g i cally ( 6 ) . However, rel i ef of l eg symptoms and im proved back-related fu nctional sta tus were present in t hose i nitially receiving surgical treat ment. Si motas et al. utilized a nexion-based stabi l ization exercise program with analgesics and epidural steroid injections i n a group o f pat i ents a l l considered to be surgical candidates ( 1 1 5 ) . At 3 years fol l ow-up , 80% o f patients were at least somewhat satisfied w i t h the results. Degree o f spi nal cord narrowing was not s ig nifican t ly correlated with outcom e. Age and degree of scoliotic deform ity were both pos i t ively cOlTelated with poorer ou tcomes. Katz studied pat ients who elected to have surgery and reported on long-term fol l ow-up data at 1 0 years t hat: 60% to 80% of patients are satisfied enough that t hey wou ld have the surgery again ( 56 , 5 7 ) . Accord i ng to Padua et al . , 4 years after spinal stenosis surgery, a l t h ough referred pai n was i mproved , physical aspects o f hea l t h-related qual i ty of l ife continued to show severe impairment ( 9 1 ) . Addi t ionally, t here

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905

were no si gnifican t E M G differences be fore and after surgery ( 9 1 ) . A number o f factors have been found t o be associ ated w i t h surgical outcome-co-morbid i t ies, degree of spinal cord narrowi ng, female sex , and Waddel l's non-organic signs ( 5 2 , 5 7 , 77 , 1 20) (see Table 3 7 .4). According to Katz e t al . t h e most i mportant pre dictor of greater walk i ng capaci ty, m i lder symptoms, and greater sat i s faction with surgery was pre-opera tive self-rated h ealth as good or exce l l e n t ( 5 7). It was concluded that co-morbi d i t ies are an i m portant risk factor of a poor recovery ( 5 7 ) . Hurri e t a l . found t h a t t h e degree o f spi nal canal narrowi ng correlates more wit h d i sabi l i ty ( as mea sured with the Oswest ry i ndex) t han does t h e choice o f treatment (conservative or su rgical ) , age, sex, or body m ass i ndex ( 5 2 ) . M ariconda et al . reported that canal diam eter innuences the response to conserva tive care, but not surgical care ( 7 7 ) . Surgical patients who h ad a poorer o u tcome were more l i kely to be female, whereas h av i ng a narrower canal was not rel evant . Sprat et al .'s fol l ow-up study focused o n t h e fol low i n g outcomes: leg pai n , pai n w i t h wal k i ng, and Wad dell's non-organic signs (see Chapter 9) ( 1 20); 5 8 . 3% pati e n ts who u nderwe n t operation were deemed a success. Using exact logistic regression analysis, Wad dell's non-organic signs ( N OS ) were the only sign i fi cant lisk factor (odds ratio: 0 .648 , 95% C I : 0 . 3620 .9901 ) . The authors concluded , "This suggests thal i l l ness behavior can play an important role in deter m i ning results of treatment, even in such a highly organic disorder as spinal stenosis." M o re detail e d analysis revealed that for females w i t hout aorta calcification ou tcom e is predicted based on canal d i ameter ( less than 0 . 3 0 5 predicted fai lu re ) ( 1 20 ) . For males without aorta calci fication, outcome i s predicted based on Waddel l's N OS ( h igher score more failure ) . For females with calci fi cation, no predictors were fou n d . For males with cal cification pretreatment VAS predicted ou tcome ( h igher score 66/ 1 00 predicted failure ) . Thus, sub c l inical vascu lar factors are in ferred to be i m portant such as arterial insufficiency at the spi nal l evel . The study reco mm ended that stenosis patients u n dergo color echo Doppler ( du pl ex scan) exa m i natio n .

Factors Related to a Poorer Outcome With Spi nal Stenos i s Surgery Table 37.4

• • • •

Co-morbidi ties Degree of spinal cord narrowing Female sex High Wadd e l l non-organ ic s igns score

906

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...


: ...

... .

.

. . ...

Because long-term data suggest that surgical outcomes are somewhat better than those for conservative care, is

Symptoms or Signs Suggestive of Cardiopu l m on ary Disease

Table 37.6

•

i t u n wise to recom mend a trial of conservative care before surgery?

• • •

Amundsen et a l . showed that whereas surgical out come is s li ghtly better than for conservative care, there is n o d i fference in surgical outcome in indiyjd uals who have i t sooner versus a fter an unsatisfactory outcome wit h conservative care for 3 to 2 7 m on ths ( 3 ) . Thus, conservat ive care i s still advisabl e since t here is no deterioration in su rgical outcom e as a resu lt o f waiting and surgery a lways carries an iatro gen i c risk, especial ly in the elderly.

Exertional Risk Assessment ACSM and AHA Risk Assessment Recommendations

W i t h the benefits o[ exercise and physical activity so c l ear, it is im portant that the risks associated with activity be identified. S i lent myocardial ischemia is believed to affect between 2 and 5 mil l ion individuals ( 7 6 ) . Thus, screen ing asym ptomatic ind i viduals for risk of cardiac complications w i th activity is i mpor tant. Two major national organizations h ave issued guidel ines for screening for risk factors associated w i t h exertional activities, the American C o l l ege o f Sports Medicine (ACSM ) ( 1 ) and the American Heart Association (AHA) ( 3 3 ) (see Tables 3 7 . 5 to 3 7 . 8 ) .

Limitations o f ACSM and A H A Risk Assessment Recommendations

The ACSM and AHA both recommend exercise stress testing [or older indiyjduals before starting a yjgorous exercise program . They also recommen d such testing

• • • • •

Ischemic pain , d isco m fort in the chest, neck, jaw, arms Shortness of breath at rest or with ni i l d exertion D i zziness or syncope Orthopnea or paroxysmal noctu rnal dyspnea Ank l e edema Palp i tations or tachycard ia Interm i ttent c l aud ication Known h eart murmur Unusual fat igue or shortness o f breath with usual activities

for most older persons before starting a moderate exer cise program. H owever, most forms of exercise stress testing were not designed for individuals older than 75 ( 3 8 ) . Therefore, screening tests to identify those people at risk with physical exertion need to be reviewed [or their applicability across the age spectru m . T h e A C S M distinguishes moderate [rom vigorous activity based on maximal rate o[ oxygen consump tion (V02max), but this is difficult to measure in older individuals ( 3 8 , 1 02 ) . Furthermore, the mathematical calculations required are not su fficiently accurate in this population ( 3 8 ,66). The AHA guidelines use max imum capacity to define exercise intensity but do not describe the met hod of its assessment. Gill concludes that these guidel ines are designed [or identifylng risk factors associated with exertion i n young and middle aged adu l ts N OT in older persons ( 3 8 ) ! A major problem w i t h exercise stress testing i n those o lder t han 7 5 i s t h a t many individuals with asymptomatic coronary artery disease (CAD) wou ld be identified leading to an escalation o f invasive car diac procedures ( 1 3 3 ) . In [act, there is a l ac k of evi dence o [ health benefit supporting such aggressive evaluati on and intervention , whereas there is evi dence of iatrogenic risk ( 2 3 , 8 2 ) .

Table 37.7 Table 37.5

H ealth Screening for P hysi cal

Act i v i ty ( 1 )

• •

•

•

•

Physical Ac t i vi t ies Read iness Questionnaire ( PAR-Q ) ( 1 7 ) ( see appen d i x ) I dent i fy patients for w h o m physical activity might be inappropri ate or should have medica l advice Eval ua te for signs and symp toms suggestive of cardiopulmonary disease or coronary artery disease

• • •

• •

Coronary Artery Risk Factors

Age: men older than 4 5 ; women older t han 5 5 Fam i l y h i story: M I or sudden death younger than 55 years in fat her/brot her or younger than 65 in mother/sister Current cigarette smoking Hypertensi �n : more than 1 40/90 mm H g Hypercholesterolemia : Total serum cholesterol more than 2 00 m g/dL or H DL less than 35 mg/d L Diabetes m el l i tus Sedentary lifestyle


Table 37.8 •

•

•

I n i t ial R isk Stra t i fication

Apparently hea l t hy : asy m ptomatic and no more than one major coronary risk factor I ncreased risk: signs & symptoms o f 30 mm) at fol l ow-up. Pain, dis abi li ty, and impairment (ROM and strength) were a l l w e l l-correlated. Both ROM and strength were lower i n surgery patients than in heal thy can troIs. The most l i m i ted ROM was cervical extension. Grip strength was equal when comparing surgical patients to healthy subjects. Fouyas et al. performed a systematic review of surgery for cervical spondylotic radicu lopathy or myelopathy and stated t hat "it is not c lear whether the short-term risks of surgery are offset by any long term benefits" (20). A recent Cochrane group review reported t hat "discectomy alone has a shorter opera tion t i me, hospital stay, and postoperative absence from work t han d i scectomy with fusion, wh ile there is no statistical d ifference for pain rel ief and rate of fusion. It also appears that fusion techniques that use autograft give a better chance for [-usion than inter body fusion techniques that use a cage, bu t other aLI t come variables coul d not be combined" (3 1 ) .

Risk Factors for a Poor Recovery

According to Ostelo e t a l . (2005) i t was found that high treatment expectancy was associated wi t h a favorable outcome on perceived recovery and func tional status at the 3- and the 1 2-month follow-ups (49) . The patient's treatment expectations also have been shown to be i mportant in predi c t i ng ou tcomes in low back pain (34), as well as for surgery for sci atica (4 1 ) . Taking pain m edication and a poor func tional sta tus at basel i ne were associated wi th poor perceived recovery and functional status at both follow-up measurements (49) . Leg pain and back pain at base l ine were associated with residual leg and back pain at the 3- and t he 1 2-month follow-up, respectively. Depressive symptoms and the presence o[ pain i n m u l t iple regions o f the body both predicted a poor outcome with l umbar discectomy at 2-year follow-up (3 3 ) . I t was suggested that such patients be referred for cogni t i ve-behavioral m anagement not surgery. Early pre-operative outcome-at 2 months-is a rel i able i n di cator of I -year outcome in l umbar disc surgery patients (26) Accord i ng to Rompe et al . (5 5 ) those at risk for dif ficult recovery post-surgery are: •

I ndividuals older than 50 vs 35 to 45

•

More than 20% overweigh t

•

Increased motor dysfunction

•

Long delay before surgery

•

M u l tiple surgeries

Chapter Thirty-Eight: Role of Non-Operative Spinal Specialist

LaCaille (3 8 ) reported that predictors o[ poorer out come fol l owing I C LF i n c l uded tobacco use, depres sion, and l i t igation. According to Craton (see Chapter 7), the complica tions of f·usion surgery include hardware malalign ment, hardware (a i l u re, pseudarth ro s i s , adjacent segment disk degeneration, and infection. Plain radio graphs are typically the first d iagnostic tec hnique i n this patient popu lation. Lucent areas noted adjacent to pedicle screw hardware suggest hardware loosening. For spinal stenosis surgery, the most i mportant predict o r of greater walking capaci ty, m i l der symp toms, and greater satisfaction w i t h surgery was pre operative sel f-rated hea l t h as good or exce l lent (3 6 ) . I t was concluded t h a t co-morbidities are an i mpor tant risk factor of a poor recovery (3 6 ) . For an terior cervical decompression a n d fusion male sex, non-smoking, greater segmen tal kyphosis, and a low pain and disabi l i ty l evel are preoperat i ve predictors of a good outcome (52 ) . I n particular the magni tude of t he cervical kyphosis was the most sig nificant pred ictor of outcome.

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92 7

Carragee et al. reported that by l i fting postoperative restrict ions return to work was accelerated and there were no increased complications ( 1 0 ) . M ost even went back to work w i t h i n 1 to 2 weeks. Eck and Ri l ey suggest return to p lay can occur within 6 to 8 for non-contact sports and 4 to 6 months for contact sports after m icrodiscectomy ( 1 7 ) .

Lumbar Fusion

Lumbar fusion patients are encouraged to get out of bed t he morning after their surgery. They wal k as much as possible from that poin t on. The restrictions postoperatively are to do no bendi ng, l i fting, or twist i ng (BLT). Li fting restrictions are simi lar to the micro scopi c discectomy. Rehab i l i tation is not begun in the first 3 months after spinal fusion . The patient is encouraged to walk as m uch as possi ble. The driving restri ctions are simi lar to microscopic discectomy. Eck and Riley suggest return to play can occur after I year for non-contact sports and is not recommended at all for con tact sports fol l owing spinal fusion ( 1 7).

Postoperative Restrictions

Microdiscectomy

Spinal Stenosis Decompression

Watki ns (65 ) has described the basic activity restric tions postoperatively. From the m i n u te t hey wake up fTom the surgery, they should wal k as much as pos sible. There are no restrictions on the l i m i t and type of wal k i ng that they do. They are not to perform bendi ng or l i fti ng. Not h i ng heavier t h an a coffee cup [or 2 weeks, not more than 20 pounds for 6 weeks, and no bend ing forward wit hout flexing the knees and squa tting. They are to l i m i t their seating to 20 minutes and get up, wal k arou nd, and sit back down . No silt ing on l ow, so ft couches/ch airs. N o driving for 3 weeks. They can b e driven, b u t the increased in tradiscal pressure w i t h drivi ng and the potential of being caugh t on the freeway and having their back start to hurt cou ld cause flair-up. The key is to wai t u n t i l annular disruption has h ad a c hance to begin hea l i ng before i ncreasi ng spinal stress. At 2 weeks postoperat ively, an i ntroductory core stabi l i zation program is introduced. The woun d is checked a t 2 weeks and t h e n activity l evels are increased fTom the onset of physical t herapy accord ing to what t heir capab i l i t ies are.

Spinal stenosis decompress ion patients are encour aged to stand and walk i m mediately a fter surgery and walk as much as possible [Tom that point on. Reha bili tation is normally begun at 6 weeks with a gent le core stabilization trai n i ng program and restrictions postoperatively are similar to microscopic lumbar dis cectomy. Eck and Riley suggest return to play can occur after 4 to 6 months for a lami nectomy and after I year for a Fusion ( 1 7 ) . Contact sports are not recom mended.

Clinical Pearl

A Cochrane Collaboration systematic review concluded that there is no evidence that patients need to have their activities restricted after a first l u m bar m icro-discectomy surgery (48).

Cervical Fusion

One level cervical fusion does not require the patient to wear a brace. The patient is encouraged not to do any l i ft i ng more than 1 0 pounds [or 6 weeks, avoid overhead work, and to begin rehabili tation at 6 weeks doing a basic stab i l i ty exerc ise program. No cervical strengthening or cervical ranges of motion exercises are encou raged in the first 6 months. The exercises shoul d em phasize neu tral postural a l ignment (e.g., Brugger rel i ef position). Cervical retraction and dor sal gli d i ng mobil i zations are s trictly avoided. They are encouraged to work from the boltom up. Use of t he t ru n k , h i ps, and c hest to produce proper cervical al ignment. At two to t h ree months post-op, the patient i s assessed wi t h x-ray and/or CT scan for sol id fusion. After 3 months, the patient begins rehabi l i ta tion and is progressed back to normal activities. N o

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head con tact sports are a ll owed i n t he first 6 months. Evel-y sports ac t i v i ty proceeds accord i ng to their abi l i ty to do the core stab i l i zation c hest-out exerc i ses. In terms of return to professional sports, after a cer vical fusion microscopic discectomy, we i nsist that the patient be able to do advanced stabilization and func tional training prior to return to competi tion. Moder ate stabi l i zation tra i n i ng allows some sports specific exercises and a return to practice. It is i m portant to em phasi ze core stab i l i zation with cervical problems, because of the partial alignment capabil i ty for head contact sport; l eg strengthening and leg flex i bi lity is cri t ical for proper pos ition of the body in order to play head contact sports. N eck strengtheni ng is a compo nent of return to head contact sports, but t h is is one of the last thi ngs to be begu n . Normal pain free range of motion is a prerequi s i te to return .

Rehabilitation

Nu merous studies have shown the beneficial effects of rehabi l i tation [or postoperative recovery. A Cochrane Collaboration systematic review concluded t hat there is strong evidence for i n tensive exercise programs after 4-6 weeks postoperative (47) . There is no evi dence such programs i ncrease t he re-operation rate. Ostelo et a l . reported t h a t behaviora l graded ac tivi ty a fter first-time l u m bar d i sc surgery was not superi or to t rad i t i onal physical therapy (48 ) . I t was concluded that such patients shoul d not be viewed as s i m i lar to c h ronic pain patients. A fun c t i onally based ra ther than psyc hological ly oriented t ra i n i ng pro gram may be a l l that is required. It appears that supervised t raining is superior to a home-based program ( 1 4 , 1 6,37,67). Dolan et al . stud ied exercise vs. reactivation advice and found that exer cise gave supelior resul ts ( 1 6). All patients had sciati ca with MRI documen ted herniated disc. All patients had ei t her fai led 6 weeks trial of conservative care or had severe motor loss. Treatment postoperatively the first 6 weeks all patient received advice about exercise and return to activi ty. They received encouragement to return to ful l act ivi ties as soon as possible. •

•

•

•

Spec i fical ly i n formed they cou l d return to ful l ac tivi t ies a s soon as t hey could tolerate the speci fic activity Patients were told that m ost people return to work i n 1 to 2 weeks As i de from wound precau tions no ot her postoperative rest ricti ons were given Patients were told to expect some back and l eg pain postoperatively, that t h i s was " normal"

At 6 weeks rando m i zation to exerc ise or a control group occun-ed. The control group received no more care. The exercise group performed a 4-week exercise program consisti ng of two l -hour exercise c lasses/ week which included aerobics, stretch i ng, and trunk condi ti o n i ng. Pai n , disabi l i ty, and spi nal function i mproved more in the exercise group than the non exercise group at fol l ow-ups between 6 and 52 weeks postoperat ively. Dani el son et al . compared a vigorous stabi l i zation program to a m i l d home exerci se rou t i n e for pat i en ts receiving m icrodi scectomy for sciatica ( 1 4) . The sta b i l i zation program was 8 weeks in lengt h . The home program consisted of two to t h ree home exercises. The resul t s were that the stab i l i zation trai n i ng group reported more i mprovement at both 6- and 1 2-month follow-ups. Y i l m a z et al . com pared t h ree groups after t heir first l u m bar m icrodiscectomy (67 ) . One group received supervised stabi l i zation exerc i ses, another home exerci se, and a t h i rd no exerc i se advice. All patien ts were exam i ned once before the exercise pro gram and agai n 8 weeks later. The supervised exer c i se group i m proved the most i n terms of pai n rel ief and fun c t i onal parameters (trunk, abdo m i nal , and l ow back strength ; back mobi l i ty). Kje lby-Wendt and Styf compared early active t ra i n i ng (EAT) versus si mple activity modification (SA M ) advi ce for patients havi ng a microdi scectomy for sciatica (3 7 ) . SAM patients received pre-operative advice about h ow to rise from bed fTom a s ide-lying position, to assume side l ying, supine l y i ng, and semi-Fowler posi tions. Postoperatively in the first 6 weeks they were trai ned in mild exercise� focused on the abdomi nals and t h ighs. After 6 weeks the exer cises progressed to include mob i l i ty training in spine flexion and l ateral flexion. They were given recum ben t exercises, but not upright or fu ncti onal ones. EAT patients rece ived pre-operat ive t rai n i ng in s i t t i ng, standi ng, and lying advi ce to maintain l or dosis. They were taugh t how to rise from bed fro m a prone posi tion and encouraged to in crease daily act i v i ti es postoperatively such as daily walks. Post opera t i vely t hey received tra i n i ng in pain coping, passive nerve m o b i l i za t i o n (first day postopera t ivel y ) , passive extension exerci ses (5 days post opera t i vely (cobra ) ; and passi ve flex ion (8 weeks postoperatively). Funct ional stabi l i za tion trai ni ng started at 6 weeks. At 6- and 1 2 -eek follow-ups the EAT group had sig nificantly less pai n and i ncreased mobi l i ty. At 2-year fol low 88% of EAT group were satisfied with their out come versus 6 7% in the control group. Hakkinen et a l . reported disappointing l ong-term compli ance w i t h home exerci se presc riptions and suggested, "Progressive load ing, supervision of train-


i ng, and psychosocial support is needed i n l ong-term rehabi l i tation programs to maintain patient motiva tion" (2 8 ) .

Chronic Pain Management Interventions In severe, chronic neck and back pain patients fusion surgery is often considered. However, alternatives should be explored before recommending fusion for chronic spine pain without leg or arm symptoms. Such alternatives include a CB program, m u ltidisciplinary pain management, or interventionist methods.

Cognitive-Behavioral Approach

A CB approach is necessary for i n tractable c hronic pain patients (see C hapters 1 4 and 3 1 ) . This approach typicall y i nvolves patient education c lasses along with t herapeu tic exercise i ncorporating quota-based, graded exposures to speci fi c feared s t i mu l i . C B classes o r sessions address t h e patient's worries and fears and teaches them simple, safe, and effec tive methods to reduce these apprehensions.

Clinical Pearl

A recent, randomized controlled trial showed that inten sive rehabil itation is more cost-effective than surgical stabi l ization [or chronic back pai n patients (53). The rehabil itation was more successr"ld in returning patients to work.

Multidisciplinary Pain Management

A comprehensive, mul tidisc i p l inary b iopsychosocial approach involves the above C B model along with strategies which address return to work obstacles (employer, compensation system, etc.) as well as co morbid psychological i ll ness. M u l tidisciplinary care (psychol ogist, pain m anagement speci a list, physical therapist) and workplace i nvolvement are keys to suc cess in these most complex cases.

I nterventionist Methods

There are a number of invasive options other than surgery for chronic back pain . Intradiscal electrother mal therapy and implantable t herapies, which include spinal cord stimulation and i mp lantable i n trathecal drug adm i n istration systems are available for pain management associated with chronic, unrelenting pain.

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Intradiscal Electrothermal Therapy (lDET)

I nt radiscal elec trothermal t herapy is stri c t l y [or patien ts with central axial pain and evidence of in ter nal disc derangement determi ned by flexion/extension studies showing significant vacuum phenomenon and discogram procedure identifying the level of concor dant pain . The most recent evidence on intradiscal electrothermal therapy shows that the results are at best a 50-50 proposition and in many locations t hey are no longer performed. In blief, i ntradiscal electrothermal therapy involves the insertion of the catheter i nto the disc. A probe is advanced which i s self-co i l i ng fol lowing the lami na tions of the annulus. The coil is then heated expecting to denature the collagen fibers of the disc shrinking them and enhancing their stiffness. Com p l i cations from this procedure are generally related to the possi bil i ty of i n fection by penetrating the skin, misdirecting o f the probe with potential damage to associated nerve and/or spi nal cord.

Implantable Therapies

I mplantable t herapi es consist primarily o r two modes. They i nclude spinal cord stimulation systems that are p l aced inside the spinal canal posterior to the dorsal columns. The second i s the use medica tion pumps, which are pl aced again inside the spi nal canal . Both of t hese approaches are used in patients with i n tractab l e pain that has not been able to be managed effectively through medication or conserv ative manual procedures, and the pati ent h as failed or is no longer a surgical candidate. Patients who h ave i m planted electrical sti m u la tors can be treated effectively with manual me thods for other complaints; however, no use of electrical or u l trasoun d modali t i es should be considered because they m ay i nteract with the implanted bodily system causing damage to the patient.

• CONCLUSION

It is important for HCPs who specialize i n spine prob l ems to u nders tand the continuum from m i n imalist care, such as reassurance and reactivation , to in ter ventionist care, such as i njections and spinal surgery. H C Ps caring for patients with chronic, unremitting p a i n m u s t be aware o f d i agnostic and t rea t me n t options that are outside of their own specialty. Pati ent centered care mandates that the diagnostic or thera peutic methods should serve the patient's goals-such as i ncreasi ng social participation and physical hmc tion. Ideal ly, the least invasive procedures wou ld be attempted first, but i f these are u nsuccessful more

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aggressi ve stra tegies should be d iscussed w i t h the patient in a shared-decision m aking manner.

Audit Process


What are the indications for l u mbar epidural i njections?

•

What is the role o f oral s teroid m edications?

•

What i s the success rate for differen t spinal surgeries?

•

How wou ld patients who at-e l ess l ikely to have a good outcome with surgery be identified?

•

What specific activi ty restrictions should be given to patients following various spinal surgeries?

• REFERENCES 1 . A m undsen T, Weber H, Nordal HJ, et a1. Lumbar spinal stenosis: conservative or surgical management? A prospective lO-year study. Spine 2000;25: 1 424- 1 436. 2 . At las SJ, Kel ler RB, Wu YA, Deyo RA, Singer D E . Long-Term Outcomes of Surgical a n d Nonsurgical Management o f Sciat ica Secondary t o a Lumbar Disc Hern iation: 1 0 Year Results fTom the Maine Lumbar Spine Study. Spine. 2005 ;30:927-93 5 . 3 . A t l a s SJ , Keller R B , W e UA, Deyo RA, Singer D E . Long-Term Ou tcomes o f Surgical a n d Nonsurgical M anage m e n t of L u m bar Spinal Stenosis: 8 to 1 0 Year Results I'Tom the Maine Lum bar Spine Study. Spine 2005 ;30:936-943 . 4 . Benz RJ , I brahi m Z G , Afshar P, Garfin SR. Predict ing compl ications i n elderly patients undergoing l u m bar decompression. C l i n Orthop Relat Res. 200 1 ; 3 84 : 1 1 6- 1 2 1 . 5 . Botwin KP, Gruber RD, Bouch l as CG, Torres-Ramos F M , Freeman TL, Slaten WK. Complications of fluo roscopica l ly gu ided t ransforaminal lumbar epidural inject ions. Arch Phys Med Rehab i l . 2000;8 1 : 1 045-1 050. 6 . Botwin K P , Gruber RD, Bouchlas CG, Ton-es-Ramos F M , H anna A, Rittenberg J, Thomas SA. Complica tions of fluoroscopically gui ded caudal epidural injections. A m J Phys Med Rehabi l . 2 00 1 ;80: 4 1 6-424. 7 . Botw i n K P , Gruber RD, Bouch las CG, Torres-Ramos F M , Sanel l i JT, Freeman ED, Slaten WK, Rao S. Flu oroscopically guided l um bar transformational epidural steroid i njections in degenerative lumbar stenosis: an outcome study. A m J P hys Med Rehabi l . 2002 ; 8 1 :898-905. 8. Botwin KP, Castellanos R, Rao S, H anna AF, Torres Ramos F M , G ru ber R D , Bouchlas CG, Fuoco GS. Compl ications o f fluoroscopically guided inter lam i nar cervical epidural i njections. Arch Phys M ed Rehabil. 2003 ;84:627-6 3 3 . 9. Brooks P M , Day R O . Nonsteroidal anti i n flammatory drugs-di fferences and s i m ilarities. N Engl J M ed . 1 99 1 ; 3 2 4 : 1 7 1 6- 1 7 2 5 .

1 0. Carragee EJ, Han MY, Yang B , Kim D H , Kraemer H , B i l lys J . Activity restrictions after posterior lumbar discectomy. A prospective study of outcomes in 1 52 cases w i t h no postoperative restrictions. Spine. 1 999;24:2346-235 1 . 1 1 . Can-agee E J , Chen Y , Tanner C M , Truong T, Lau E, Brito JL. Provocative discography i n pat ients after l i m i ted l umbar discectomy: A control led, random ized study of pain response in sy mptomatic and asym ptomatic subjects. Spine. 2000;25:3065-307 I . 1 2 . Can-agee EJ, Barcohana B , Alamin T, van den Haak E. Prospective controlled study of the development of lower back pain in previously asymptomatic sub jects undergoing experim ental d iscography. Spi ne. 2004;29: 1 1 1 2- I I 1 7. 1 3 . Carragee EJ, Ala m i n TF, M iller J L , Can-agee J M . D iscographic, M RI and psychosoc ial determ i nants of low back pain disabi l ity and rem ission: a prospective study in subjects w i t h benign pers istent back pai n . Spine J . 2005 ; 5 : 24-35. 1 4. Danielson J M , Johnsen R, Ki bsgaard SK, Hellevik E. Early aggressive exercise for postoperative rehab i l i tation after discectomy. Spine. 2000;25: 1 0 1 5- 1 020 . 1 5 . Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ . Lumbar spinal fusion. A cohort study of com pl i ca tions, reoperations, and resource use in the Medicare population. Spine. 1 993; 1 8 : 1 463-1 470. 1 6 . Dolan, P, Greenfield K , Nelson RJ , N elson IW. Can exercise therapy i m p rove the outcome of m icro discectomy? Spine. 2000; 1 5 : 1 523- 1 532. 1 7. Eck JC, Riley LH 3rd. Return to play a fter l u m bar spine conditions and surgeries. C l i n Sports M ed . 2004;23: 367-379. 1 8. E uropean Guidelines for the management of acute nonspecific low back pain in pri mary care-preliminary draft-http://www. backpaineurope.org 1 9. Faciszewki T, J ensen R, Rokey R, Berg R. Cardiac risk stratification o f patients with sym ptomatic spinal stenosis. Clin Orth Rei Res 200 1 ;384: I I 0- 1 1 5 . 20. Fouyas I P , Stat h am PFX, Sandercock PAG, Lynch C . Surgery for cervical radicul omyelopathy. The Coch rane Database of Systematic Reviews 200 1 , Issue 2 . 2 1 . France R D , Houpt J L , E l l inwood E H . Therapeu tic effects of antidepressants in chronic pain. Gen Hosp Psyc h i atry. 1 984;6: 5 5-63 . 2 2 . Gabriel SE, J aak k i m a i nen L , Bom bardier C . Risk for serious gastro i n testinal c o m p lication re lated to use of nonsteroidal a n t i - i n flam matory drugs: A m e t a-analysis. Ann In tern Med 1 99 1 ; 1 1 5 : 7 87-796. 2 3 . Getto CJ, Sorkness CA, Howell T. I ssues in drug management. Part !. Antidepressants and chronic nonmalignant pai n : a review. J Pa in Symptom Manage. 1 987;2:9- 1 8. 24. G ibson JNA, Waddell G . Surgel-y for degenerative l u m bar spondylosis. The Cochrane Database of Systemati" Reviews 2005 Issue 3 . 2 5 . Greene J M , Winickoff RN. Cost-conscious prescrib i ng of nonsteroidal an ti-inflammatory drugs for adul ts wi th arth ri t i s . A review and suggestions. Arch Intern Med. 1 992; 1 52 : 1 995-2002. 26. H akkinen A, Yl inen J, Kaut iainen H , Airaksinen 0, Herno A, Kiviranta I. Does the outcome 2 months


after l u m bar disc surgery predict the outcome 1 2 months later? Disabil Rehabil . 2003;25 :968-97 2 . 27. H akki nen A, Kuu kkanen T, Tarvai nen U , Y l i nen J . Trunk muscle strength i n flexion, extension, and axial rotation in patients m anaged with l umbar disc herniation surgery and i n healt hy control subjects. Spine. 2003;28 : 1 068- 1 073. 28. H a kk inen A, Yl inen J , Kau t i ainen H, Tarvai nen U , Kiviranta 1 . Effects of h o m e strength tra i n i ng and stretching versus stretc h i ng alone after l umbar d isk surgery: a randomized study with a I -year fol l ow-up. Arch Phys Med Rehabil. 2005;86: 865-870. 29. H uskisson EC, Woolf DL, Balme HW, Scott J, Frankl i n S . Four new ant i - i n llammatory drugs: responses and variat ions. B r Med J. 1 976; 1 : 1 048- 1 049. 30. H uskisson Ee. How to choose a non-steroidal anti i n flammatory drug. Clin Rheum Dis. 1 984; I 0:3 1 3-323 . 3 1 . Jacobs WCH , Anderson P G , L i mbeek J , Willems PC, Pavlov P. Single or double-level anterior i n terbody fusion tech niques [or cervical degenerative disc dis ease. The Cochrane Database of Systematic Reviews 2004, Issue 3 . 3 2 . Jenkins DG, Ebbutt A F , Evans C D . Tofra n i l i n the treat ment of low back pain. J Int Med Res. 1 976;4:28-40.

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43. M a n c h ikanti L , Staats P, S ingh V, Schultz O M , Vilims B D , Jasper J F et a l . Evidence-based practice guideli nes for interven tional techniques i n the man agement o f chronic spinal pain. Pain Physician 2003;6:3-8 1 . 44. Mazanec OJ. Medication use i n sports reha b i l i tation in Functional Rehabi l i tation of Sports and Muscu loskeletal Injuries. K i bler WB, Herring SA Press J M (eds). Aspen, Gaithersburg, Maryland, 1 998. 4 5 . N elemans PJ , de B i e RA, de Vet H CW, Sturmans F. Injection therapy for subacute and c h ronic benign low-back pain. The Cochrane Database or Systematic Reviews 1 999, Issue 4 . 46. N iemisto L , Kalso E , Malm ivaara A, Seitsalo S, B u rri H , . Radiofyequency denervation [or neck and back pain. The Cochrane Database o f Systematic Reviews 2002, Issue 3 . 4 7 . Ostelo RW, d e Vet H C , Waddell G , Kerckhoffs M R, Leffers P, van Tulder M . Rehabilitation fol l owing first-time l umbar disc surgery: a systematic review w i t h i n the fyamework of the Cochrane col laborat ion. Spine. 2003 ;28 :209- 1 8. 48. Ostelo RWJG, de Vet HCW, Berfelo MW, Kerchhorfs MR, Vlaeyen JWS, et al. E ffectiveness of behavioral graded activity after first-t ime l u m bar disc su rgery: short term results of a randomized control led trial . Eur Spine J. 2003; 1 2 :6 3 7-644.

3 3 . Junge A, Dvorak J, Ahrens S. Predictors of bad and good outcomes of l u mbar disc surgery. A prospective c l i nical study w i t h recommendations for screening to avoid bad outcomes. Spine. 1 995 ;20:460-468.

49. Ostelo WJGR, Vlaeyen JWS, van den Brandts PA, de Vet CWH . Residual complaints following l u m bar disc surgery: prognostic i ndicators o[ outcome. Pain. 2005; 1 1 4 : 1 77-1 85 .

34. Kal auokala n i 0 , Cherk i n DC, Sherman KJ, Koepsell TO, Deyo RA. Lessons from a trial of acupunct u re and massage for low back p a i n : patient expectations and t reat ment effects. Spine. 200 1 ; 2 6 : 1 4 1 8- 1 424.

5 0 . Padua L , Padua R, Mastan tuoni G , P i tta L , Caliandro P, A u lisa L . Health-re lated qua l i ty of l i fe after surgi cal treatment for l um bar stenosis. Spine 2004;29: 1 670- 1 6 7 5 .

3 5 . Katz I N , Lipson SJ , Chang LC, Levine SA, Fossel A H , Liang M H . Seven- to 1 O-year outcome o f decompres sive surgery [or degenerative l u m bar spinal stenosis. Spine. J 996;2 1 :92-98.

5 1 . Peloso P , Gross A, H aines T, Trin h K, Goldsm i t h C H , Aker P, Cervical Overview Grou p. Medicinal and I njection t herapies for mechanical neck disorders. The Cochrane Database of Systematic Reviews 2005 Issue 3 .

36. Katz IN, Stucki G, L i pson SJ, Fossel AH, Grobler LJ, Weinstein I N . Predictors of surgical outcome in degenerative lu m bar spinal stenosis. Spine. 1 999;24:2229-2233.

5 2 . Peolsson A, Hedlu nd R , Vavruch L , Oberg B. Pred ic tive factors for the outcome of an terior cel-vical decompression and fusion. Eur Spi ne J . 2003; 1 2 :274-2 80.

37. Kjelby-Wendt G, Styf J . Early active tra i n i ng after l u m bar discectomy. Spine. 1 998;23:2345-2 3 5 1 .

5 3 . R i vero-Arias 0 , Campbell H, Gray A, Fai rba nk J , Frost H , W il son-MacDon a l d J . Surgical stab i l i za tion o f the spine com pared w i t h a program o f i ntensive reh a b i l itation for the management o f patients w i t h chronic l o w b a c k pai n : cost u t i l i ty analysis based on a randomi zed controlled tria l . B M J . 2005 ; 3 3 0 : 1 2 3 9 .

38. LaCaille RA, DeBerard MS, Masters KS, Colledge A L , Bacon W. Presurgical biopsychosocial factors predict multidimensional patient: outcomes of i n terbody cage l u m bar fusion. Spine. 2005 ; 5 : 7 1 -78. 39. L i petz JS, Malanga GA. Oral medications in the treatment of acute low back pain. Occup med. 1 998; 1 3 : 1 5 1 - 1 66 .

54. Robinson J P , B rown P B . M edications in low back pain. Phys Med Rehabil C l i n North A m . 1 99 1 ;2:97-1 26.

4 0 . Loeb OS, Ah lqu ist DA, Talley NJ. Management of gastroduodenopathy associated with use of non steroidal anti-i n na m m atory drugs. Mayo Clin Proc. 1 992;67:3 54-364.

5 5 . Rompe J D , Eysel P , Zollner J , Heine J . Prognostic criteria for work resumption a fter standard l u m bar d iscectomy. Eur Spine J . 1 999;8: 1 32- 1 37 .

4 1 . Lutz GK. Butzla[f ME, A tlas SJ , Keller RB, S inger DE, and Deyo RA, The relation between expectations and outcomes i n surgery for sciatica. J Gen I ntern Med 1 999; 1 4 :740-744.

56. Rosenblatt R M , Reich J , Dehri ng D. Tricycl i c anti depressants in treatment of depression and chronic pain: analysis of the supporting evidence. Anesth Analg 1 984;63 : 1 025- 1 03 2 .

42. Malanga G, Nadler S. Nonoperative Treatment of Low Back Pai n . M ayo C l i n Proc, November 1 999:74; 1 1 3 5- 1 1 48 .

5 7 . Scott DL, Roden S, Marshall T, Kendall M J . Varia tions in responses to non-steroidal anti-innammatory drugs. B r J C l i n Pharmacol. 1 982; J 4:69 J -694.

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5 8 . Soli A H , Weinstein W M , Kurata J, McCarthy D. Non steroidal anti-innammatory drugs and peptic u lcer disease. Ann I ntern Med. 1 99 1 ; 1 1 4: 307-3 1 9 . 59. Sprat KF, Kel l el- TS, Szpalski M , Vandeputte K , Bunzburg R. A predictive model for outcome after conservative decompression surgery for l u m bar spinal stenosis. Eur Spine J 2004; 13 : 1 4-2 J .

the Cochrane Coll aboration Back Review Group. Spine. 2000;25:250 1 -25 J 3 . 6 4 . van Tulder M W , Touray T, Furlan A D , Solway S , Bouter L M . M uscle relaxants [or non-spec i fic low back pai n . Cochrane Database Syst Rev. 2003 ;2. 6 5 . Watkins R. L u m bar d isc i njury i n the ath lete. Clinics in Sports Med.icine 2002 ;2 J : J 47- 1 64.

60. Triano n , Rashbaum RF, Hansen DT. Openi ng access to spine care in the evolving market: i ntegration and com mun ication. Top C l i n C h i ro. 1 998;5 :44-52 .

66. World H ea l t h Organization. I n ternational Classi fica tion of Funct ioni ng, Disabil ity and Hea l t h : ICF, World Healt h Organ i zation, Geneva, 200 J .

6 J . Triano n . C h i ropract i c person nel i n t h e 2 J s t century depends on strategy today. Top C l i n C h i ro. 2000 ; 7 : 2 7-32.

67. Yilmaz F , Yilmaz A, M erdol F, Padar D, Sah i n F, Kuran B . Efficacy o r dynamic l u mbar stabil izat ion exercise i n l u m bar m icrodiscectomy. J Rehabil Med. 2003 ; 3 5 : 1 63- 1 67.

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68. Yl i ne n n , Savolainen S, Airaksinen 0 , Kau tiai nen H , Sal o P, H akkinen A . Decreased strength a n d mob i l i ty i n pat ients after anterior cervical di skectomy com pared with hea l t hy subjects. Arch Phys Med Rehabi l . 2003 ;84: 1 043- J 047.

From Guidelines to Practice: What is the Practitioner's Role?

Alan Breen

Clinical Practice Guidelines Clinical Vignette A Brief History of Clinical Practice Guidelines The Route From Research to Practice Standards Guidelines and Gurus: The Problem of RCTs

Learning Objectives


•

•

The Development of Guidelines Tools, Rules, and Relevance: Good and Bad Guidelines

•

•

Semantic Discrepancies Implementing Guidelines Guidelines and Musculoskeletal Rehabilitation

Appreciate the cultural values surrounding clinical practice guidelines Explain the different ways in which guidelines are produced and used Appreciate the issues t h at lead to controversy in the selection of research evidence Evaluate a guideline For practice use Identify why a guideline may be difficult to implement

•

Devise ways to implement guidelines

•

Audit practice against a guideline

Audit and Guideline Implementation The Future

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Clinical Practice Guidelines

"Systematically developed statements to assist prac titioner and pat ient decisions about appropri a te health care for specific clinical circumstances" (19).

Clinical Vignette

An American lady w i t h a h igh public profile tells t h e story o f her frustrated quest for effective treatment for her painflJI shoulder. From the start her friends i nsi sted that she must have "the best" and arranged a next-day appointment with an ort hopedic surgeon who speciali zed in the exact placement of steroid injections. This helped, but the pain returned. Unable to sleep, but not wishing to offend her friends, she contacted a sports physiotherapist whose skills were widely sought by world-class athletes. The physiother apist also saw her quickly in his clinic and diagnosed a muscle imbalance as the underlying impediment to recovery. He then applied muscle energy techniques and electrical stimulation. That night she was in great pain. She returned to the physiotherapi s t the next day and was given cold treatment and ultra sound, which eased things slightly. Still seeking the righ t treatment, and on the recommendation of yet another close friend, she saw that friend's chiroprac tor, who examined her whole spine as well as both shoulders and told her he believed t h e actual site of the problem to be i n her neck. After six treatments consist ing of spinal manipulation she was no worse, but no beller, and she did not go again. This lady was not only i n constant pain, without sleep and rapidly succumbing to depression, but also anxious at the thought of having to tell her three closest friends, who constantly inquired about her shoulder, that their unshakable fai th in their favorite pract itioners had done her no good at all. When she could no longer avoid i t and to muster the strength to face them, she finally went to her general practi tioner (GP) in pursu i t of sleepi ng pills and s tronger analgesics. Suspicious of joint pain that wakes in t h e night, the G P ordered a n ESR and a test for rheuma toid factor, which came back pos i t i ve. The cause of her symptoms was not tendon i t is, muscle imbal ance, or cer·vical dysfunction, but acute rheumatoid arthri t is. The rest of her story is about coming to terms wi th what was to become an aggressive form of rheuma toid di sease that completely changed her life and career and made pain, deformity, and the juggling of anti-inflammatory drugs the dominant feature of it. Of course, no other initial care could have prevented the inevitable, but her s tory is a dramatic i llustration of the cost of inappropriate and fragmented care, based on the misguided belief that specialist reputa-

tions should di splace the basic principles of good practice. Clinical practice guidelines are about current best practice and generally address basic principles. It is because they are "tools and not rules" that they only replace clinical decision-making when these deci sions are extremely bad (19). By contrast, guidelines are t h ere to sit comfortably wi th deci sion making for i ndividual patients (52). The practitioner's role in care remains central. This chapter explores that role i n the context of spinal rehabilitation when guide l ines and clinicians come into contact.

A Brief History of Clinical Practice Guidelines

Health care has traditionally been guided by the col lective wisdom of clinicians, often based on whatever research was available but, until relat ively recently, wi thout a way of verifying cause and effect . In the 1940s, with the development of statistical methods, this changed. When Sir Austin Bradford-Hill used a randomized controlled trial (RCT) to compare strep tomyci n and PAS (para-aminosalicylic acid) with usual care in the treatment of tuberculosis in 1948, the dramatic results established the RCT as a new aid to clinical decision-making; especially in the field of pharmacotherapeutics (28). Tuberculosis has since, however, come to be re garded as the last great epidemic and decisive con clusions from s i ngle RCTs have become rarer. Furthermore, the limitations of RCTs are still a source of controversy. Nevertheless, the pressure to make choices between competing treatments in the face of limi ted budgets made their prominence inevitable (22 ) . Dur i ng the "clinical outcomes" movement of the 1980s, evidence was sought (usually unsuccessf1.111y) to substantiate many drug claims, leading to an explo sion of research. From then until the time of writing, health care policy in all treatment areas, both at prac titioner and organizational level, has been increas ingly influenced by such research. By the early 1990s, the volume of literature was so great that the need to summarize and interpret for practice was apparent. The age of "evidence-based health care" had arrived. Another factor that occupied the thoughts of health planners was the explosion of costs. Commissioners of care sought order in the form of wri tten guidelines to contain unrestrained choice. In America espe cially, many gLlidelines were based on the consensus of local groups rather than systematically evaluated research, which caused government s to appoint groups of experts to produce guidelines that were "evidence-based" and develop a methodology for using them (19).

Chapter Thirty-Nine: From Guidelines to Practice: What is the Practitioner's Role?

Main Methods of Guideline Development •

Informal consensus

•

Formal consensus ( Delp h i , etc.)

•

Evidence-based

•

Exp l i c i t approach ( details time, cost, etc.)

The Route From Research to Practice Standards

Guidelines are specific to the encounter between patient and practitioner, but they are not the only route [Tom research to practice standards (see box) (21 ) .

Other Approaches t o Practice Standards •

Total Quality I mprovemen t / Management

•

Managed Care Systems

•

Hea l t h Tec h nology Assessment

•

Heal th Care Needs Assessment

--

935

working in health services to promote health, pre vent and treat disease, and improve rehabilitation and long-term care ("technologies" in this context are not confined to new drugs or pieces of sophisti cated equipment). The purpose of HTA is to try to ensure that high-quality research information on the costs, effectiveness, and broader impact of health technologies is produced in the most effective way for those who use, manage, and provide care. It also tends to be performed on a national scale. A more local (and liberal) approach to care stan dards is Health Care Needs Assessment (see box) (1). This is a tool for a managed route to care that also incorporates the effects of costs and clinical efrec tiveness but is based on the existing impact of the condition(s), the local community's view on what is important, and on the nature of existing services. Here, care standards can be audited against the need identified by the Needs Assessment. However, when there are complex service issues (e.g., multifaceted interventions, important social and occupational influences, and multiple provider types) local con sensus can be difficult to reach.

Health Care Needs Assessment

Other schools o[ thought hold that rather than offer evidence-based recommendations for treatment de cisions, it may be more appropriate to take a Total Quality Improvement (TQI) approach and establish an actual protocol to be followed, evaluate the out comes, and then revise the protocol in the light of this (13 ). This is a more top-down approach that also addresses costs, but allows the practitioner and patient less fTeedom of choice. It is appealing to health care commissioners because of its accessibil ity to direct management under a Total Quality Man agement (TQM) scheme that decides the important outcome measures and manages the process of care by data. The outcomes chosen as being desirable tend to depend on national cultures and funding processes. In the United States' managed care sys tems, for example, the outcomes are (37): •

Functional health status (including risks and well being)

•

Clinical outcomes

•

Satisfaction against need

•

Costs (direct, indirect, of health and social care)

National policies towards different interventions are sometimes based on a Health Technology Assess ment exercise (HTA), which is an internationally rec ognized term that covers any method used by those

•

Incidence/Prevalence/ Natural H is tory ( w i thout interven t ion)

•

Cost w i th o u t intervention

•

Local c u l tu re on: o

M ost important impact

o

M ost important measures

o

Existing services

Evidence-based guidelines influence practice in a different way by addressing the clinical encounter itself (47 ) . As such, they are much more patient centered and somewhat less threatening to the clini cian. The disadvantage of often not addressing cost is balanced against giving the flexibility to take indi vidual patient circumstances into account. The route [Tom research to the eventual improvement of practice standards through guidelines (Fig. 39.1) has a number of stages, from the evaluation and synthesis of evidence into coherent statements, to linking these statements to recommendations for practice and the formulation of criteria for use in assuring care quality. At each stage when judgments on points of view are needed, there should be a con sensus, or appraisal process. Once a guideline's development is complete, its rec ommendations can be translated into review criteria

936

--


groups to expose the "baseline" findings before engaging in discussion of what the slandards should be. For practitioners, this can be a very valuable edu cational exercise ( 2 5 ) .

Research

+

Systematic review

+ +

/

Evidence synthesiS

Consensus

From Recommendations t o Practice Standards Evidence

temen

i /

Consensus

Recommendations

Appraisal

Review Criteria

Systemat i cally developed statements t hat can be used to assess the appropriateness of specific hea l t h care

+

decisions.

Clinical practice guideline

/ Clinical audit

+t

RevieW criteria

Protocols

Protocol

�

Comprehensive set of cr i t eria for a s i ngle c l i n ical con" d it i o n or aspect of organization. Standards

Standard

Figure 39.1 The rou t e from I"esearch to prac"

tice standards.

( 4 ) . These are statements on which the imple mentation of recommendaLions can be lested. For example:

Recommendation: "Carry out diagnostic triage. " Review criterion: "The records show that diag nostic triage was done and the patient's back complaint was categorized as either serious pathology, root pain, or unclassified back pain." IL is desirable that review criteria are based on re search evidence, prioritized on the strength o[ this and the innuence on patient outcomes, measurable, and appropriate [or the setting for which they are recommended. IL may be desirable lo group criteria into protocols, or attribulable actions, that follow in sequence. This is helpful when the guideline user is not likely to be familiar with the basis for a set o[ recommendations, or what order to approach them in. The developmenl of review criteria is necessary to be able to audit guideline use. Practitioners can then see, in a group of actual patients, where they are con sistent with guidance and where they are not, and be able to critically reflect on this. The proportion of Limes that events agree is called "standards" (see the box.) . Again reflecling the "tools and not rules" ethos o[ guidelines, it may not be advisable to always expect slandards to reach 100%. This applies, for example, when the review criteria do not cover all contingen cies ( 40 ) . Standard setting is a process that must be carefully managed as a partnership between practi tioners and the other stakeholders in care. It some times follows an initial audit round of practitioner

Percentage of events t hat should comply w i t h the criteri o n .

Guidelines and Gurus: The Problem of RCTs

The pursuit of certainty in health care is one problem of naivety (see the box) in that modern empirical sci ence, and particularly statistics, provides only esti mates in domains thal may themselves be the subject of dispute. This puts pressures on guideline develop ers born of the biases and polilical interests that are generated. This combined with the non-uniformity of patient characteristics means lhat good guidelines should keep to simple concepts with clear limita tions. The conventional view of the RCTs as a "gold standard" is less easy to sustain in rehabilitation disciplines. Problems of Naivety •

Limitat ions of science

•

B ias/p o l it i cs in the production of guidelines

•

N on-u n i formity of patients

However, RCTs are still probably the best way to com pare the effectiveness of treatments and infer a causal relationship between intervention and outcome. Un fortunately, their profile in health science is such that much more is often expected. They are parlicularly well-suited to the comparison or interventions with very clear outcomes (such as survival), with test treat ments that are simple to apply (such as pharmaceuti cals) in patients whose diagnoses are well-defined (such as tuberculosis). When these margins are bluned, there is a tendency to reject randomized trials


as being too rigid of a method of assessment. This applies in such heterogeneous conditions and treat ments as are presented in rehabilitation. A better approach is to understand these limitations and their solutions, as well as the fact that they a�e not the only source of research evidence for guidelines (7). Table 39. 1 suggests alternative methods and their indica Lions. For example, cohort and case-control studies are pre[erred options for research to inform recom mendations about natural history, diagnosis, and risk of rare events. A key concept is that RCTs do not eval uate treatments but differences between treatments. Because benefits are relative, it is necessary to inter pret their results in this light.

The Development of Guidelines

The context [or clinical guidelines is determined by their professional use. That requires discussion be tween professionals and that discussion is most pro ductive if it centers around how clinical judgment operates, and what constitutes good standards of care. The process begins with the identification of a manageable number of key clinical decisions that the guideline is to inform. This is a balance between the importance of the decisions and the availability and quality of the research evidence. Once the key clini cal decisions have been decided on, the steps that fol low are: 1.

Finding the evidence (using an explicit literature search strategy)

2. Appraising the evidence by:

Components of Evidence •

Research (e.g., natural h istory, treatment effects etc . )

•

Clinical expertise

•

Patient preferences

(From Sackett, Rosenberg & Grey, 1996)

To complete the guideline development process can take considerable resources and if these are absent the feasibility is weakened (see the box). The time required depends a lot on how many decisions and circumstances the guideline is meant to cover and how complex the evaluation of interventions needs to be. This will determine the skills required of the guideline development group and how the work is to be divided between its members. It is also necessary to look towards the implementation of the final prod uct when considering developing it. A guideline that suggests a change from what has become standard practice needs to be very transparent about the rea sons for its recommendations. Similarly, recommen dations that could have legal penalties i[ not followed (such as a recommendation to adhere to new legisla tion) must be properly authorized ( 2 3 ) . The following box shows some of the issues to be considered in deciding of the feasibility of developing any guideline.

• •

4.

Grading the evidence statements

S.

Formulating evidence-linked recommendations

Evidence, however, is not just that which comes fTom research (see the box) (42). Guidelines that deny the value and participation of clinical experts and the preferences of patients start at a disadvantage when it comes to implementation. Furthermore, there is still

Table 39.1

1. 2. 3. 4.

•

Time

•

Compl exity

•

Skills

•

Local standards

•

Coverage

•

Legal imp l ications

•

Implementation

Methodological Limitations of RCTs and Their Solutions

Limitation

Do not address subgroups Do not address complex treatments Seldom address long-term outcomes Seldom address risk

( from Breen & Feder, 1 999)

937

debate about the relative merits of unidisciplinary ver sus multidisciplinary guidelines, both in development and use (15,44) .

Feasibility of Developing a Guideline

Characterizing the studies Grading the studies 3. Formulating evidence statements

--

Solution

Research subgroups for RCTs separately Factorial trial designs Large cohort studies tracking outcomes Case-control studies

938

--


The development of evidence-linked guidelines does not remove the need for consensus, nor does their validity depend principally on the clinical, or even the research, expertise of the development group but on finding a reproducible and relatively unbiased method of iden tiEying the relevant evidence, and explicitly linking recommendations to it. The follow ing box shows the techniques commonly used.

Techniques for Processing the Evidence for Guideline Production •

Systemat ic reviews

•

Narrative summaries or evidence

•

Evidence tables

•

M eta-a nalysis

•

Decision analysis

•

Balance s h eets I isting benefits, h arms, or costs for each recommendation

Tools, Rules, and Relevance: Good a nd Bad Guidelines

The practitio ner in receipt of a guideline has the cru cial role in deciding whether it is good or bad for patient care. Orten, however, this is limited to consid erations other than those of methodological quality, such as whether they sit comfortably with practice procedures (see Implementation below) . A summary of what to look for is shown in the following box.

Characteristics of Good Guidelines •

Based on rel iable and up-to-date evidence and proress ional consensus

•

Address key c l i n ical decis ions

•

Deal w i t h heterogeneity

Table 39.2

• • • • •

Criteria for Appraisal of Clinical Guidelines (Version 1) •

Scope and purpose

•

Stakeholder i nvolvement

•

Rigor of development process

•

Clarity and presen tat ion

•

App l icab i l i ty

•

E d itorial i ndependence

(AGREE collaborative group, 2000)

Benefits and Harms of Guidelines

Potential Benefits of Guidelines •

Because it is the practitioner who ultimately deter mines the appropriateness and use of guidelines, it is best to be clear about what benefits and harms they can promote (53) . The main ones are suggested in Table 39.2. The assessment of the validity of clinical practice guidelines is an important, and legitimate, educa tional exercise for practi tioners. Once gu ideli nes are disseminated for clinical use, however, it is too late to amend them. Furthermore, many practition ers are inundated with guidelines. It is therefore worth investing in an appraisal process to ensure that implementation stands a chance through accep tance by the people they will affect. For example, work has been underway through a collaborative group for the Appraisal of Guidelines, Research, and Evaluation in Europe to establish criteria on which guidelines can be appraised (see the box) ( 2 ) . This paves the way [or the production of international guidelines. In preparation for this in the area of back pain, Koes et al. compared low back pain guidelines [Tom 1 1 different countries published between 1 994 and 2000 and found generally simi lar diagnostic and therapeutic recommendations ( 2 4 ) . This comparison was vital to the development of the European Commission's Acute Low Back Pain Guidelines (18 ) .

Continuous professional development Inform research agenda Reduce poor quality care Improve care Decrease health care costs Reduce medico-legal liability

Potential Harms of Guidelines • • • • •

Poor patient care (biggest risk) Inflexibility Disruption of practice Threat to livelihood Medico-Iegal liabilit-y (if not following)


Semantic Discrepancies

In a field as diverse as musculoskeletal pain, some acknowledgment of hermeneutical problems is needed. What, for example, is meant by the term "spe cific back exercises, " and how does the 'evidence help us? The UK Acute Back Pain Guideline Development group of the 1990s considered these to be exercises that were specific in the muscle groups that they tar geted, or in the sequence or nature of the regime ( 50 ) . The trial evidence was that they were, as a whole, less effective for acute back pain than the interventions to which they had been compared. The evidence state ments agreed on was therefore, "From the evidence available at present, it is doubtful that specific back exercises produce clinically significant improvement in acute low back pain. (author's underlining) or that it is possible to select which patients will respond to which exercises." A second evidence statement con tinued: ". . . there is some evidence that exercise pro grams and physical reconditioning can improve pain and functional levels in patients with chronic low back pain" (author's underlining) . By "specific, " the guideline was attempting to indicate exclusion of regimes aimed at overall strength and endurance and to make clear where such regimes could be helpful. This was broadly accepted in the appraisal process of the Guideline and its subsequent Audit Tool in light of the recommendation: "Consider atTanging reactivation/rehabilitation for patients who have not returned to ordinary activities and work by 6 weeks." By contrast, a subsequent Cochrane review enti tled "Exercise Therapy for Low Back Pain" offered the evidence against specific back exercises for acute back pain without such a qualification, provoking critical comment objecting to the unqualified infer ence (49, 30 ) The lesson from this is that a guideline, or HTA process, requires a consensus, as well as a sys tematic review process, followed by a recommenda tion that renects the evidence in clinical scenarios, whereas an evidence statement in a systematic review lacks the pro tection of such contextual clarification. A [' tion. Most of the reviewers of trials o[ this interven-

Table 39.3

See LBP as a significant health problem Received a copy of RCGP Guideline Made use of RCGP Guideline1' Intend to use in future Priority levels of back pain care: Low: 21%; Medium: 5 1 %; High: 44% (n

=

"Consider (referral for) spinal manipulation for patients who are (ailing to return to normal activities."

Guideline developers, therefore, have an obligation to contextual logic and its communication and se mantics can conspire to defeat this. It is here that the strength of multidisciplinary guidelines over uni disciplinary o nes becomes apparent, for these have to find a way of expressing recommendations in terms that are clear and logical to practiboners [Tom a variety of backgrounds, as well as their patients.

Implementing Guidelines

In a survey of local audit groups in England, audit administrators were asked about the attitudes toward the problem of back pain and the use of the UK Acute Back Pain Guideline. The results (Table 39.3) are instructive. To use guidelines o ne must first

Use of RCGP Guideline'"

57, response rate: 59%)8

511 57 47/ 5 7 27/57 111 57

939

tion ignored the study by Meade that showed a deci sive, if modest, superiority of chiropractic over fast track hospital outpatient management for subacute and chronic low back pain ( 3 3,3 4 ) . This has often been objected to on the basis that an important manipulation trial was ignored, whereas in this trial, both treatment arms used manipulation at least some times. Reviewers of manipulation as an intervention would have found this to be outside of their criteria for the selection of studies. In the European Acute Back Pain Guideline, the evidence on manipulation had been summarized in one Cochrane review, which characterized the inter vention negatively as being no better than other treat ments which were found effective (3) . This evidence was strong for the subacute and chronic phases, with less availability of acute studies with acceptably long term follow-up ( 50 ) . However, the patient types, inter ventions, and outcome measures varied greatly and, despite the weight of evidence, a few trials of reason able quality had a negative result. This rendered the evidence conflicting, making it impossible to produce an unequivocal evidence statement about manipula tion. Instead, the recommendation agreed on was:

Altitudes and Use of the UKlRCGP Back Pain Guidelines by NHS Audit Groups

Attitude to Problem

--

Raising awareness Clinical Audit Setting standards Local guidelines Change services Local education

10/27 8/ 27 2/27 1 1/27 3/ 27 10/ 27

940

--


receive them. Ten out of 57 respondents said they had not. Of those who had, only approximately half had used them for any purpose, even though a sub stantial majority saw the problem as significant and 79% regarded it as a medium or high health care pri ority. Of the many choices available to local groups about when to use guidelines, the most popular were: education, raising awareness, or making local guidelines. Very few had actually used them to audit standards, set standards, or change services. Guidelines, even if they do survive rigorous apprai sal processes intact, do not, therefore, automatically change behavior. The UK Acute Back Pain Guidelines and the Clinical Standards Advisory Group report and Epidemiology Review of the subject that preceded it, were thought to have made little difference to general practitioner behavior or to the availability of many of the services it recommended (50, 11,12, 29, 5) . One problem with implementing guidelines on musculoskeletal rehabilitation is the relative newness of the psychosocial elements in care. The debate about whether practitioners should have these responsibili ties started in the 1970s and has probably not ended yet (17) . Learning about psychosocial assessment and intervention is an educational issue, which fits well with the evidence about successful implementation and suggests that professionals must be personally engaged in the process before practitioner behavior will change. They must have some kind of resonance with usual practice (51, 21) . However, it may be better to target a number of barriers concurrently, rather than rely on single initiatives (39) . Practitioners could, for example, implement guidelines into their practices within a public awareness, educational, or research program in which they have a part (especially if these are highly interactive) . The educational power of vignettes illustrating "what works" within the system is becoming increasingly appreciated. Change man agement techniques can be especially effective where practitioners work in groups (14) , especially with their closest colleagues present. This makes learning about new ways of working "collectively reinforced, inter nalized, and tacit" within the practice itself (20) . The theoretical model for this is the "Communities oFPrac tice" model (27) , in which novices to the new evidence become owners of it by virtue of their participation. This implies a work-based learning approach that benefits the organization and the learner (10). The Guidelines for the Evidence-Based Management of Acute Musculoskeletal Pain produced by the Aus tralian Acute Musculoskeletal Guidelines Group (35) contain similar themes to the European Back Pain Guidelines (18), but spreads across all musculoskele tal areas. The Australian Guideline also uses concise information sheets for each complaint, summaries of findings, and their limitations and summaries of the key messages for each topic. It is more amenable to

holding the attention of its clients in a work-based learning scenario than most evidence-based guide lines. This kind of approach has been shown to result in improvement in back pain management (13) and may also equip practitioners to help shape local ser vices together to better meet patient needs.

Key Points in the Implementation of Guidelines •

Operate directly on the cons u l tation process t h rough: o

R es t ru c t u red .-ecorcls

o

Patient-specific rem i nders (e.g. , note ir patient has acute back pai n )

o

A u d i t sys t em for guideline in opera t i o n

•

Absence of bias

•

Resonance wi t h usual practice

•

M ul t i - faceted i n i tiatives to promote i mplemen tati o n

•

Use i n educa tional , public awareness, o r research programs

•

Group pract ice "change management" process

There remain, however, significant barriers, fore most among which are patient preferences (43) . A good example of this is the desire for X-rays when patients do not realize that it adds little but a radia tion risk to most cases of acute undifferentiated back pain (48). In practice, this is an opportunity to for mulate a response that promotes patient confidence, compliance with care recommendations, and strat egy for re-activation by demonstrating knowledge, concern, and commitment when explaining the true nature of the symptom. Readiness to undertake spe cial investigations when necessary combined with emotional support and reassurance is the other side of this coin that assumes that patients are equal part ners in their care and must have the opportunity to understand the reasons for the cI in ical decisions which affect them. Frequently, guidelines do not address the man agement decisions that professionals regard as impor tant (43) . Here, the practitioner may lose interest. This is, however, less likely if the guideline contains agreed recommendations based on up-to-date evi dence about c�re that will affect clinical outcomes. It is important to understand the reasons for the omis sions, which are usually that there is either insuf/1cient evidence to support a recommendation or agreement by peers that it is not fundamental in care. The practitioner is then at liberty to make deci-


sions based on her/his own clinical judgment. A spe cial case of this is when the practitioner does not see the patients to which the guidelines refer, such as physiotherapists working in hospital s with waiting lists which excludes them fyom seeing patients with acute back pain ( 3 8 ) . Barriers t o Implementation of Guidelines •

Pat ient preferences

•

Management decisions not addressed

•

Does not apply to patients seen

•

Practitioner desire to "tailor" in formation

•

Poor abi l i ty to use recommendations

•

Poor access to faci l i t ies

•

In formation not standardized

•

Comfort wit h current pract i ce

•

Ot her pressures

•

Inconsistentlabsent leadership

•

Poor in terprofessional integra t i on

( from B i rd 2000)

Generalists may fail to implement guidance about rehabilitation, simply because they do not have an interest in the area and are comfortable with current practice ( 6 ) . This can be addressed with consistent leadership that promotes integration with other ser vices and funding and support for evidence-based care and education. I t can be part of a practice out reach program which, although it has been shown to improve knowledge and understanding, is less able to change attitudes ( 3 1 ) . Organized quality improvements can, therefore, change practice, improving patient outcomes, link ing professionals through common goals, and reduc ing tribal ism and isolation (46). The rewards incl ude getting access to wider services and support while sharing skills and data. Unfortunately, this is all new and there are few examples to follow-onl y princi ples and applying steep learning curves over a short time. Additionally, there is an undeniable decrease in clinical autonomy and an increase in accountability that pits the professional's self-esteem against the spirit of clinical quality improvement. This raises thoughts about whether future heal th care is to be corporate or isolationist. There is, however, emerg ing evidence that the successf·ul impl ementation of guidelines does improve both processes and patient outcomes, particularl y with regard to limiting the need for (generally more expensive) secondary care services (4 1 , 3 2 , 26,45 ) .

94 1

G uidelines and Musculoskeletal Rehabilitation

In the rehabilitation of the spine, it is essential to evaluate the relationship between neuromuscular performance, distress, and disempowerment in patients to be able to intervene at the appropriate lev els. Current research addresses these fairly explicitly and, therefore, there is scope for evide nce based recommendations for practice. However, evi dence in this field is also plagued by heterogeneity, notably in the characteristics of the subjects, the way their conditions are dirrerentiated, the instru ments used to ev aluate treatment outcomes, in the methodologies deployed by researchers and the way results are analyzed This is the current weakness of the evidence. Although unidisciplinary research and guidel ines reduce the v ariations and semantic dis crepancies, they do not assist continuity of care when it crosses disciplines. Multidisciplinary guide lines, however, are immediately confronted by all the factors brought about by the sources of hetero geneity. Imprecise descriptors, intangible v ariables, and the persistent use of metaphors confound this process even further. An advocate fTom the profes sion concern ed who can promote the message s of a multidisciplinary guidel ine may be one solution to this ( 9 ) . A s impenetrable a s these obstacl es may seem, and recall ing the vignette with which this chapter opened, if there is one approach that is optimal for a person at a given point in their condition, it should be av ailable regardless of which practitioner that person sees fi rst. The need for integrated care is well recognized ( 1 6 ) . A possible solution t o the fTagmentation o f care is to return to the issue of key clinical decisions. For example, for acute undifferentiated back pain, most guidelines advise triage, avoidance of X-rays, psy chosocial assessm ent, pain control with analgesics at regular interval s, avoidance of bed rest, adv ice to stay active, and the consideration of manipulation and/or strengthening and reconditioning if symp toms are persisting beyond a few weeks. Discipline specific practice habits might, for example, dictate that all patients receive analgesics and none receive manipulation, or the converse. A more sensible ap proach would be to arrange analgesia for patients who need pain control to remain active and have no contraindications for their use, and to use manipu lation as a pain control and arresting measure for patients who meet the criteria for its LI se and show signs of not recovering early in the episode. It is sen sible for evidence-based interventions to be used according to patient need rather than practitioner preference.

942

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Part Seven : Implementing the Functional Paradigm

Audit and G uideline I m plementation

•

Construct data collec t ion form to record compl iance w i t h criteria aga i nst patient records

Audi t i s the final stage i n the route to practi ce stan dards based on gui delines, but i t i s not a way of i m plementi ng them. Cli ni cal audi t was devi sed a s a conti nuous process of self-apprai sal, recomm ended especi ally for conti nuous professional development programs. The audi t cycle (Fi g. 3 9 . 2 ) i s repeated unti l the desi red standard of each audi t (revi ew) cri teri on i s reached. To get the best out of audi t, collaborati on i s hi ghJy desi rable. If performi ng an off-the-shelf audi t wi th i n a practi ce or professi onal group, th ere should b e a meeti ng to di scuss why i t i s bei ng done and how. There should be a clear data collecti on strategy that i s specific to the cli ni cal setti ng and i t i s best, i f pos si ble, to i nvolve an audi t support or advisory group and to engage al l stakeh olders. Health care auth ori ties, be they regulatory bodi es, commi ssi oners of health care, or practi ti oner groups can deci de the proporti on of times a gui deli ne recom mendati on should be met and audi t practi ce to reveal the match wi th thei r i deal standard. The followi ng box describes a typi cal aclivi ty li st [or faci li tati ng gui deli ne audi t by a gro up.

•

I n i t iate d iscuss ion about the aud i t (e.g. , practice meet i ng, study group mee t i ng, large group mai ling of materials)

Stage 2 - First Audit Round •

Circulate audi t forms and instmctions for first aud it roun d

•

P ract i tioners sample pat ient records, complete forms, and return [or process i ng

•

Audi t data comp iled and fed back to prac t i t i oners ( see example)

•

Group d iscuss ion of aud it fi ndi ngs fol lowed by changes to improve standards before second aud i t roun d (e.g. , 6 mon t hs later)

Stage 3 - Second Audit Round •

Circulate aud i t forms and ins t ructions for second aud i t round

•

Prac t i t ioners sample patient records, complete forms, and return [or process ing

•

Aud i t data comp i l ed and fed back to prac t i t ioners ( completion of aud i t loop)

Auditing Guideline Use by a G roup •

Stage 1 •

-

Preparation for the Audit

Convert the guidel i ne's recommendations to review criteria ( Figure 39. 1 ) (or access an off-the-shel f audit)

•

Group d iscussion of aud i t fi ndings followed by changes to improve standards and when to repeat aud i t cycle in t he future

( For rUrlher exam ples or audit systems in musc u l oskeletal rehabilitation, see www . i m rci .ac.ukiAudit/audil . h l m l )

Decide when the aud i t w i l l occur, who it is aimed at, what the inclusion and exclusion cri teria are, number o f pat i e n t records to be aud i ted, what educati onal material shou l d accompany it, etc.

Identify audit criteria

Audit practice

Compare practice with exllclt standards Figure 39.2 The aud i t cycle.

T h e first round of such an audi t gives a baseli ne return on whi ch to consi der i mprovements, servi ng the ai ms of conti nuous professi onal development. T abl e 39.4 shows a conci se example of how the results mi ght be reported to practi ti oners. Thi s i s the time to th i nk about wh at the standards should be and h ow to reach the target needed to achi eve the necessary ch ange. After a peri od of time, a second audi t round i s conducted and the findi ngs reported, whi ch com pletes the audi t loop. Although audi t i s the final stage i n th e route to practi ce standards based on gui deli nes, i t i s a vehi cle for gui deline i mplementati o n, not a strategy in i tself. Audi t and feedback are useful processes on whi ch to promote compli ance wi th gui delines but reedback alone i s generally i nsuf6ci ent to ach i eve i mplementa tion ( 3 6 ) .


--

943

Table 39.4 Example of Clinician Report Form Acute Low Back Pain Audit in Primary Care January 2003 Audit Population: Practiti onersFirst Audit Round

86 Patients ( 1 st 6 weeks of episode)-843

Cohort Findings

My Findings

The record shows that: 1 . Diagnostic triage was calTied out 2. Psychosocial factors were considered

98% 67%

99% 96%

Patients with nonspecifi c back pain were: 3 . Not X-rayed 4. Advised to stay active 5. Not prescribed bed rest

87% 85% 97%

92% 93% 95%

. . . and if not resolving at 4-6 weeks from onset: 6. Rehabilitation was initiated

67%

72%

Review Criterion

The Future

The rapid increase in the av ailability of system atic reviews through organizations such as the Cochrane Collaboration, the growth of guideline networks in many nations, and intern ational collaboration in guideline development and appraisal all mean that the ownership of guidelines may , in the future, become much more global. Patients, health profes sionals, and care commissioners will be able to ben efit h-om the experiences of implementation in other countries and avoid reinvention of solutions to gelling evidence into practice. Recently, audit has ceased to be always a paper exel"Cise, because Internet based audit has become a reality in th e care of coro nary heart disease and acute back pain, providing the possibility of crossing borders and m ore effectively sharing solutions to clinical problems. The unavoidable fact that heallh care costs money (and " every cost is somebody' s salary" ) will probably continue to be the main inhibiting factor; yet, since guidelines address interventions and not profes sions, care overlap and fTagm entation could hope fully diminish if good guidelines are implemented successfully. This will require considerable inter professional collaboration and, to some extent, the subordination of market rivalries to evidence-based practice. In a new model of service provision for spinal pain, the " preferred provider" could eventually be the individual who can demonstrate expertise against agreed criteria rather than simply claim it by virtue of a qualification. Furthermore, the coopera tion of practitioners and patients alone is not enough to ensure practice standards. Policy m akers includ ing educators, licensing bodies, insurers, employers,

state welfare agencies, professional associations, and trade unions also have major parts to play.

• C O NCLUSION

In the rehabilitation of painful musculoskeletal dis orders, tolerances and well-being are important con cepts. On the part of the patient, tolerance can be to pain, disability, im pairment, handicap, distress, or cost. On the part of the practitioner, the patient's per ceived tolerances apply, plus the practitioner's own, which m ay include symmetry and perceived nor mality of osseous position and movement, clinical course and progress, ranges of motion, strength, and endurance. Closer to hom e, the pressures of sel f im age, income, influence, and interest all im pact on processes of care. In the real world, these will never be optimal; therefore, it is important to identify clearly the aim s of rehabilitation treatment. Clinical practice guidelines, as suggested at the beginning of this chapter, give mainly basic guid ance, intended to help us to avoid catastrophes, h-ag m ented care, and poor outcomes. The key benefits to practitioners lie in their being up-to-date, reflecting the opinions of peers and experts, and addressing key issues while taking into account that no two patients are the same. This protects patient and practitioner against the consequences of basic omissions and errors i. n rehabil itation. They can unite professionals both within and between disciplines. However, this only works if they are implemented effectively. Effec tive implementation depends on a conclusive envi ronment that promotes positive attitudes towards improving care and provides both the resources and

944

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time to do this ( 3 6 ) . Its s uccess depends on th e sup port of a much wider ch urch th an practitioners .


What are the steps i n the route [yom research t o pract ice?

•

H ow does a systematic review d iffer from a meta analysis?

•

What criteria should be used t o determine when a g u i de l i ne be updated?

•

Why wou l d a guideli n e be d ifficul t to i mplement and what methods i ncrease the l i ke l ihood o f pract i t i o ner i m plementation?

•

H ow can a pract i ti o ner audit that t hey are practicing in a m a nner consistent with a gui deli ne?

• REFERENCES 1 . Acton C, Newbronner E . Hea l t h N eeds Assessment: A Step by Step Guide. York: York H e a l t h Econom ics Consort i u m , 1 997 ( h t tp://www.ac to nshapiro.co . u k ) . 2 . AGREE Col l a borative Group. Guideline Develop ment in Europe. I n t J Tech n o l Assess H eal t h Care 2000; 1 6( 4 ) : 1 039- 1 049. 3. Assendelrt WJJ , M orton SC, Y u EI, Suttorp M J , Shekel I e P G . Spinal manipulat ive t herapy [or low back pai n : a m eta-analysis or effect iveness relative to other t herapies. Ann I n tern Med 2003 ; 1 3 8 : 8 7 1 -88 1 . 4 . Baker R , Fraser RC. Development o f review cri teria: l i n k i ng gu idel ines and assessment of qual i ty. B M J 1 995 ; 3 1 1 :370-3 7 3 . 5 . Barnett AG, U nderwood M R, Vickers M R . Effect o f U K national guidel i nes on services to treat patients with acute l ow back pai n : fol low-up questionnaire su rvey. B M J 1 999;3 1 8 :9 1 9-92 0 . 6.

Bird C. Com m issioned R & D Progra m m es: I mple mentation or low back pain gu idel i nes in North Thames. London: N H S Execut ive London Regional O rfice, 2000.

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A review of t h e l i tera t u re. N H S U I n ternal report , 2004. 1 1 . C l in ical Standards Advisory Group (CSAG) . Back Pai n . London: Depart ment or H ea lt h , 1 994. 1 2 . C l i n ical Standards Advisory Group ( CSAG ) . Epi demiology Review: The epidemiology and cost of back pai n . London : Depart ment o f Heal t h , 1 994. 1 3 . Deyo RA, Sch a l l M , Bervvick D M , Nolan T, Carver P. I n novations in education and c l i nical practice: con t i n uous qual i ty i m provement ror pat ients ,,\lith back p a i n . J Gen Intern Med 2000; 1 5 :647-655. 1 4. Donleavy G D . A basic law of m anagement? In: Sanchez R & H eene A , eds. Theory Development ror com petence-based managemen t . Stamford, Con n ecticut: Jai Press I nc , 2000: 5 7-67. 1 5 . Eccles M, Clapp Z, Grimshaw J, Adams PC, H i ggins B, Purves I, Russell I . Developing val i d guidel ines: m et hodological and procedural issues from the North of E ngland evidence based guidel i ne develop ment project. Qual i ty Health Care 1 996;5:44-50. 1 6. E i senberg D M , Kessler RC, Foster C, Norlock FE, Calkins D R , Delbanco TL. U nconvent ional medicine in the U n i ted States: prevalence, costs and pat terns or use. N Engl J M ed 1 99 3 ; 3 2 8 ( 4 ) :246-2 5 2 . 1 7 . E ngel G L . T h e need [or a new medical mode l : a chal l e nge ror b i o m e d i c i ne. Science 1 97 7 ; 1 96(42 8 6 ) : 1 29- 1 36. 1 8 . E u ropean Comm ission COST B 1 3 Management Com m i ttee. E u ropean guidel i nes ror the manage ment of low back pai n . Acta Orthop Scand 2002 ; 7 3 (Suppl. 3 0 5 ) : 2 0-25. 1 9 . Field MJ, Lohr KN (eds). Gu ideli nes for C l i nical Practice: from development to use. Wash i ngton DC: Institute of M ed ici ne/National Academy Press, 1 993. 20. Gabbay J, Ie M ay A . Evidence based guideli nes or collect ively constructed "m indl i nes?" E t h nographic study of k n owledge management in primary care. B MJ 2004 ; 3 2 9 : 1 0 1 3- 1 0 1 7 . 2 1 . Grol R, D a l h u ijsen J , Thomas S, i n't Vel d C, Rut ten G, M e k k i n k H . Attribu tes of c l i n ical guide l i nes that i n fluence use of guideli nes in general pract ice: obser vational s tudy. B M J 1 998;3 1 7 : 8 5 8-86 1 . 2 2 . H i ne D. For the good that i t wi l l do: issues confronting healt hcare in the U K . J Royal Soc Med 1 999;92: 332-338. 23. H urwi t z B. Legal and pol i t ical considerations o r c l i n ical practice guideli nes. B M J 1 999;3 1 8 :66 1 -664. 24. Koes BW, Van Tulder M W , Ostelo R, Burton AK, Waddell G . C l i nical guidel i nes ror t he management o f low back pain in primary care. Spine 200 1 ;26( 2 2 ) : 2 5 04-2 5 1 4. 2 5 . Langworthy J M . Development of a c l i n ical audit pro gram in chiropractic. E u r J C h i roprac tic 1 998;46: 3 1 -39. 2 6 . Latt imer V, Sassi F , George S, M oore M, Turnbull J , M u llee M , S m i t h H . Cost analysis o r nurse telephone consul tation in out of hours primary care; evidence from a rand.o m i zed controlled trial . BMJ 2000;320: 1 053- 1 057.

Breen A, van Tul der M, Koes B, Jensen I, Reardon R, Bron rort G . M ono-di scipl i n ary or m u l t i discipli nary back pain guidel i nes? How can we ach ieve a com mon message in pri mary care? Eur Spi ne J 2005; (in press) .

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29. L i t L i e P, S m i t h L , Can t rell T, Chapman J, Langridge ], Pickering R. General prac t i t ioners' m anagement o[ acu te back pai n : a survey of reported practice com pared with c l i n ical guidel i nes. B MJ 1 996;3 1 2 : 485-488. 30. Manniche C. Letter to the E d i tor. Spine 2 00 1 ;26: 840-844. 3 1 . Markey P, Schatt ner P. Promoting evidence-based medicine in general pract i ce-t he i mpact of academic detaili ng. Fam i ly Pract ice 200 1 ; 1 8( 4 ) :364-366. 32. McGuirk B, King W, Govind J, Lowry J, Bogduk N . Safety, efficacy and cost effectiveness o f evidence based guideli nes for the management o f acute low back pain in primary care. Spine 200 1 ; 2 6 ( 2 3 ) : 26 1 5-2622. 3 3 . Meade TW , Dyer S, Browne W, Townsend J, Frank AO. Low back pai n of mechanical origi n : random ized comparison o f c h i ropractic and h ospital o u t pa tient treatmen t . B M J 1 990;300: 1 43 1 - 1 43 7 . 34. Meade T W , Dyer S, Browne W , Frank AO. Random i zed comparison of c h i ropractic and hospital o u t pa t i e n t management for low back pai n : results from extended fol low-up. B M ] 1 995;3 1 1 : 349-3 5 1 . 3 5 . Nat ional Heal t h M edical Research Counc i l , Aus t ral ian Acute M uscu loskeletal Pain Gui d e l i nes Group. Evidence-based management of acute m us culoskeletal pain . Brisbane: Australian Academic Press Pty Ltd, 2003. 36. Nat ional I ns t i t u te for C l i nical Excellence. Principles for best practice in c l i n ical audi t . Oxford: Radc l i ffe Medical Press Ltd, 2002. (www . n ice.org . u k ) 3 7 . Nelson EC, M o h r JJ , Batalden P B , P l u m e SK. I mproving Hea l t h Care, Part 1 : The C l i nical Value Compass. J Qual i ty I m provement 1 996;22(4): 243-256. 38. Newton-John T, Ashmore J, M c Dowell M. Early i n t erven t ion in acu te back pa i n . Phys i o t herapy 200 1 ; 8 7(8):397-40 I . 39. Ox man AD, Thomson M A , Davis DA, et a l . N o magic bullets: a systematic review of 1 02 trials of in terven t ions to i m prove professional practice. C M AJ 1 995; 1 5 3 : 1 423- 1 43 I . 40. Royal Col lege of General Prac t i t ioners' C l i n ical Guidelines Work i ng Group. The development and i m plementation o[ c l i nical guidel i nes. Exeter: Royal College of General Pract i t ioners, 1 99 5 . 4 1 . Rossignol M , Abenhaim L , Segu in P, Neveu A , Col let J-P, Ducruet T, Shapiro S. Co-ord i nation of Primary

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42. Sackett DL, Rosenberg W M C , G ray J A M , H aynes RB, Richardson WS. Evidence based medicine: what it is and what i t isn't. BMJ 1 996;3 I 2 : 7 1 -7 2 . 43. Scllers H , Braspenning J , Drijver R, Wensing M , Grol R. Low back pain in general practice: reported man agement and reasons for not adhering to t he gu ide l i nes in the Netherlands. Br J Gen Pract 2000;50: 640-644. 44. Shekelle PG, Woo l f S H , Eccles M , Gri mshaw J . C l i n i c a l guideli nes: developing gu idel i nes. B M J 1 999;3 I 8 : 593-596. 45. S m i t h RE. Gatekeepers and sentinels: t h e i r conso l i dated effects on i n p a t i e n t medical care. Evaluation Revievv 200 1 ;2 5 ( 3 ) : 2 88-330. 46. Sweeney G , Stead J , Sweeney K, Greco M . Exploring t h e i m plementation and development of c l i n ical gov ernance in primary care w i t h i n t h e Sou t h West Region : views from PCG C l i nical Governance Leads. Exeter: N H S Exec u t i ve Sou t h West Region-R& D Support U n i t , 2000. 4 7 . U n iversity o f York, NHS Centre [or Reviews & D is semination. E ffect ive Hea l t h Care: Get t i ng evidence into prac t i ce. London: Royal Society of M ed i c i ne 1 999;5( 1 ) . 4 8 . van Tul der M W, Assendelft WJJ , Koes BW, Bou l ter L M . Spinal radiograph ic fi ndi ngs and nonspecific low back pai n : a systema tic review of observat ional stud ies. Spine 1 99 7 ; 2 2 ( 4 ) : 427-434. 49. van Tu lder MW, M al mivaara A , Esmail R, Koes BW. Exercise t herapy for l ow back pai n ( Cochrane Review). In: The Coch l-ane Li brary, I ssue I , Oxford: 200 1 . 50. Waddell G , M cI ntosh A , H u t c h i nson A , Feder G , Lewis M . Low back pain evidence review. London: Royal College o f Gene/-al Pract i ti oners, 1 999. 5 I . Watk i n s C, H arvey 1 , Langley C, Gray S, Fau l kner A. General p ra c t i t i one/-s' use o f guideli nes in t he consul tat ion and t h e i r a L t i t udes to t he m . B r J Gen Pract 1 999;49: 1 1 - 1 5 . 5 2 . W i l son M C , Hayward RSA , Tu n i s S R , Bass E B , Guyatt G . Users' guides t o the medical l i terature. VIII: H ow to use c l i n ical pract ice gu idel i nes. B: What are t h e recom mendations and w i l l t h ey h e l p you in caring for your patients? J A M A 1 995;274(20): 1 630- 1 632. 5 3 . Woo l f SH, G rol R, H u tc h i nson A , Eccles M, Gri m s h aw J. Pote n t i a l benefit s , l i m i tat ions and harms of c l i n ical guidelines. B M J 1 999;3 1 8 : 52 7-530.


Index

Page numbers followed by l i ndicale table; t hose i n italics i nd icate figure. Abdomi nal braci ng, 1 06 respi ration and, 374, 3 8 3 Abdominal cond i t ions, spinal pai n related t o , 1 3 1 Abdomi nal exercises machine, 702 , 702 yoga-based lrai n i ng effecl of, 579 i nslruclions for, 580, 5 80-58 2 , 581 Abdominal hol lowi ng, 1 06 balance/molor con lrol tes t , 249-2 50, 250 Abdomi nal muscles, i n standing posture, 2 1 8 , 2 / 9 Abnormal i l l ness behavior, 79-80, 80t Acetaminophen, 920 Ach i l les lendon, fascia, soft tissue manipulation of, 396, 3 9 7 Acromioclavicular joi n l , man i pulalion o f, 502, 504 Active care, 4, 295-324 duri ng acute phase, 1 8- 1 9 benefi ts of, 4 biochemical factors i n , 7 causalion i n , 299 duri ng chronic phase, 20, 20t cogn i t ive behavioral l herapy in, 3 1 7-32 1 compli ance and, 322-3 2 3 , 3 2 3 t fear-avoidance bel iefs i n , 296-297 goal sel l i ng in, 297-298 motival ion i n , 318, 3 2 1 -3 2 2 , 3 2 2 t mulLidiscipli nary approach of, 32 1 for neck condi tions, 20-2 1 , 2 1 t neurophysiological factors i n , 7 pai n rel ie f options, 3 1 4-3 1 5 pai n vs. i njury i n , 298 palien l-cen tered approach , 1 7, 1 7- 1 8 , 1 8 i n prevent ion, 1 8 rat ionale for, 6-7 reac tivation advice, 297-3 1 7, 297l recovery expectations, 3 1 5-3 ] 6 reporl of findi ngs, 3 1 6-3 1 7 rest vs. activity, 300 during subacute phase, ] 9-20 Active limb movemen l , l ow back pai n classification, 803, 804 Acl ive scars, soft tissue man i pulation of, 3 98-402 Active s lraigh l leg raise tesl, 1 2

Activi t i es o f daily l iving B ri.igger defini t ion, 3 5 3 Brugger method train i ng, 3 6 3 , 3 6 5 , 365 Activi ty leve l , in low back pai n , 57 Acute phase of care, chro n i c i ty in, 1 84- 1 8 5 , / 85 Adverse n eurodynamic tension concepts, 465-466 eval uation of, 466-4 7 2 , 46 7, 469-4 75 u pper quarter, 4 7 2 , 474-4 8 5 , 4 76-485, 4 8 3 l treatment o f (See Neuromobi l i zation tec h n iques) Aerobic fitness evaluation of, 2 5 2-25 3 , 2 5 2 l b i ke tes l , 2 5 3 Harvard method, 2 5 2-2 5 3 tread m i l l testi ng, 2 5 3 Y M CA 3 -minute Bench s tep, 253 i n low back pai n , 5 7 Age Discrim i nation a n d Employment A c t of 1 967 (ADEA), 2 8 0 Agi st, Brtigger defini tion , 3 5 3 Agi sti c-eccen tric contract i o n approac h , i n Bri.igger method, 3 5 7-36 1 , 358-36 / finger flexors, 3 5 7-3 5 8 , 358 h i p rotators, 360, 360 plantar Oexors, 360-36 ] , 36 1 tru n k flexors, 3 5 8-3 5 9 , 359 trun k rotators, 359, 3 59-360 wri st flexors, 3 5 8 , 358 Agonist-antagoni s t muscles, coacl i va l i on of muscle imbalance and, 3 5-36 role in spine stabi l i ty, 3 3-34 Allodynia, 729 Alternative med icine, holistic approac h , 779 American College of Sports M ed i c i ne (ACS M), exert ional risk assessments, 906-907, 906-907 American H eart Association, exertional risk assess ments, 906-907, 906-907 American Medical Association (AMA), guide for physical impairment assessme n t , 8 American w i t h Disab i l i ti es Act (ADA) defi n i tions, 2 8 1 pre-employmen t testi ng and, 2 7 8 , 2 8 0-282 purpose of, 2 80-2 8 1 qual i fied individuals, 2 8 1 type of discrimination i n , 2 8 1 Analgesics narcotic, 920 947

948

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Index

Analges ics (contd. ) non-narcotic, 920 topical , 920 Anglo-American Col lege of Chiropractic (AECC), 668 Ankle dorsiflex ion mobi li ty gastrocnemius length, 2 3 1 , 23 1 soleus length , 2 3 1 , 23 I manipulation o r, 5 0 5 , 50 7 outcome assessment for, 1 58 Ankle Joint Functional Assessment Tool (AJFAT), 1 58 A n kylosing spondyl i t i s, spinal pai n related to, 1 29t, 131 Antalgia, spinal cervical kyphotic, M c Kenzie approach for, 343-345, 343-346 cervical torticol l i s , M c Kenzie approach for, 348-349, 348-349 coronal, M c Kenzie approach for, 346-349, 346-3 50 lordotic descri ption of, 3 3 7 , 350 M c Kenzie approach for, 349-350, 350 l u m bar kyphot ic descri ption of, 3 34, 334, 3 3 7 M cKenzie approach for, 340-343 , 340-343 l u m bar scoliotic descri ption of, 3 34, 335, 337 M c Kenzie approach for, 346-34 8 , 346-348 Anti-i n flamm a tories, 920-92 1 Anticonvulsan ts, 922 Anti depressan ts, 922 Ariel Performance Analysis System (APAS), 268-269 , 269 Arm abduction test, 76 7, 868, 868-869 Arm movements, during gai t , 2 2 1 Arm reac h, standing over head, 768, 8 3 3-834, 833-835 Arthroplas ty, knee, 90 1 , 90 1 t Articular patterns, exam ination and correction of, 563-564, 563-564 Ascending pai n pathway, 75 Assessment (See also speci fic test) diagnostic triage, 1 2 5- 1 44 employment scree n i ng, 2 7 6-290 of muscular i m balance, 203-2 2 5 outcome, 1 46- 1 63 physical performance abi l i ty test, 2 26-2 54, 260-272 of psychosocial fac tors, 1 83 - 1 96 Assoc iat ive s tage, of motor learni ng, 596 Atlantoaxial j o i n t , manipulation of, 496, 4 96 Automatic gait reflex, 5 3 7 , 53 7 Autonomous stage, of motor learni ng, 596

Back, fascia, soft t i ssue manipulat ion of, 392-394, 3 93 Back Book, The, 83 Back Bournemouth Questionnaire, 1 62 , 1 8 1 Back extension, 6 3 5 , 636 on ball, 770 machine exercise, 699, 6 99, 700 M cKenzie exercise, 768 Back extensors, s tabi l i zation exercises, 1 05-1 06 Back l i ft exercise, 6 73 Back pain (See also Low back pai n) sources of, 1 1 2 - 1 1 9 cri terion for, 1 1 3-1 1 4 diagnostic blocks i n finding, 1 1 5-1 1 6 discography i n finding, 1 1 6- 1 1 7 losers, 1 1 7 tradi tional, 1 1 3 win ners, 1 1 7- 1 1 8 Back school, 84, 896 Bal ance, in low back pai n , 1 2 , 5 7 Balance/motor con trol tests, 248-2 5 2 , 248t abdominal hollowing, 249-250, 250 cervico-cra n i al flexion test of Ju l l , 250-2 5 2 , 251 o ne-leg stan d i ng test, 248 249, 249, 249t Ball exercise core tra i n i ng, 71 9-720, 722 i sotonic tra i n i ng, 6 75, 6 78-6 79 sensory motor stimulation (SMS), 5 1 6 , 526-527 medicine core tra i n i ng, 723-726 plyometrics using, 709-7 1 0, 710 Bandura, A., 3 1 7-3 1 8 Barrier phenomenon, 389, 3 8 9-390, 493-494, 494 Bed, rising from , 304, 306 Bed rest affects of, 15, 1 6, 1 6 overemphasis on, 77-78 Bench step, for aerobic fi t n ess eval uation H arvard method, 2 5 2-2 5 3 Y MCA method, 2 5 3 , 253 Bergmark, Anders, 99, 5 8 7 B i ke testing, of aerobic fi tness, 2 5 3 B i ochemical [actors, in active care, 7 B iomechanical analysis, of physical perrormance test battery, 267-268, 269-2 70 B i omedical model of pai n, 73 vs. bi opsychosocial mode l , 84, 84t Biopsychosocial model, 72-8 7 , 26 1 for acute low back pai n , 87 algori thm for, 81 best practice approach, 82t diagnostic triage and, 80-87 goals of, 80-8 1 overview, 7 3-74, 75 -

Index

of pai n , 73-74, 75 pain i n , 73-74, 75 pai n rel ief i n , 85 patient reassu rance, 82-84 practit ioner aud i t , 86, 86-8 7 re-evaluation, 85-86 react ivation advice, 84-85 recondi tioning i n , 86 red flags i n , 8 2 , 8 2 t , 83 referral i n , 86 vs. biomedi cal model, 84, 84t yellow flags in, 82, 85-86 B i rd dog exerc ise, 1 06 , 1 08, 6 2 3 , 623-624 Body statics, pelvic obl i q u i ty and, 79 1 -796, 792- 796 Body wal k i ng, Brugger method, 366, 368 Bone scan, i n di agnostic triage, 1 3 8- 1 39, 1 38 t Bosu, 771 Bou rnemou th Questionna i re Back, 1 62, 18 1 Neck, 1 62 , 1 8 1 Brac hial plexus, upper l i m b neurodynamic tests for, 477-478 Bracing exercise, 622 Breat h i ng (See also Respi ration) abdom i nal assessmen t of, 377, 3 77 tra i n i ng for (See Respiratory trai n i ng) vs. chest, 3 8 1 chest, 372, 3 73, 3 74, 3 76-3 77 cyli ndrical , 3 7 1 deep diaphragma tic, 382 diaphragm i n , 568 l i ft i ng of thorax while, 788-789, 789 mechanics of, 568 i n motor re-education, 604-605 mou t h , 3 7 3 , 375 overbreat h i ng, 3 75-3 76 paradoxi cal , 374, 378 rhythm or, 373 Breathing exerc ises (See Respi ratory exercises) Brea t h i ng pattern disorders, 3 69-38 6 Bridge exercise, 1 03 , 1 04, 1 05 , 63 1 , 632, 770 Bri.igger, Alois, 3 5 3 Bnjgger methods, 3 52-3 69, 768 activities of daily l i v i ng train ing, 3 6 3 , 3 6 5 , 365 agi stic-eccenlri c contraction approach , 3 5 7-36 1 , 358-3 6 1 body wal k i ng, 366, 368 chain react ions and, 780-78 1 , 78 1 - 782 cog wheel model of joi n t cen t ration i n posture, 37-3 8 , 3� 30 1 , 302, 3 5 3 , 353 func tional taping, 366, 366 great diagnostic muscle loop, 3 5 3 , 353 hot rol l , 3 5 7 , 357 ideal posture i n , 3 5 3 , 355

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949

manual resistance tec h n i ques ( M RTs) lower-quarter eccentric, 450, 45 1 upper-quarter eccen tri c , 450, 45 1 pati e n t examination, 3 5 5-3 5 6 patient i nstruction, 3 5 6 pri n c i ples of, 3 5 3 rel i e f position, 30 1 -3 0 2 , 302 retrocapi tal support of the foot, 3 6 5-366, 366 rocking tech n i que, 78 1 , 782 six basic exercises, 3 6 7, 368 supine pos i tioni ng, 3 56-3 5 7 , 357 Thera-B a nd use, 3 6 1 , 362-365, 3 6 3 B rushi ng teeth , 307, 308 Bu teyko Control Pause, in respiratory tra i n i ng, 3 84-3 8 5 B uttocks, fascia, soh t i ssue mani pulation or, 394, 3 94 Cable c rossover machi n e exerc ise, 698, 6 98 Calcaneal (heel) reflex, 5 3 7-5 3 8 , 538 Calcaneocu boid j o i n t , m a n i pulation of, 505, 506 Cal i fornia Functional Capaci ty Protocol (Cal-FCP), 289-290 Canadi a n Back I nstitute, low back pain c lassi fica tion, 803 Cancer neck condi t ions related to, 854 spinal pain rel ated to, 1 28 , 1 29t Car, s i t t i n g i n a, 3 1 1 , 3 13 Cardiovascular fitness (See also Aerobi c f i tness) in l ow back pai n , 5 7 Cardiovascular problems, exertional risk assess ments for, 906-907 , 906-907 Carpal Tunnel Syndrome Questionnaire (CTSQ), 1 57 Carryi ng obj ects, 308 Cat camel exercise, 1 06, 1 0 7, 62 1 , 62 1 t , 768 Cauda equina syndrome, spinal pai n related to, 1 30 Cei l i n g effects, of outcome assessment tool , 1 49 Central nervous system i n locomotor function, 5 3 2-5 3 3 i n s p i n a l motor control, 5 8 8-592 , 589-59 / Central sen s i tization fibromyalgia and, 44 neuropathic pain and, 40-46 Centra l i zation p henomeno n , 800, 802 Centration, functional , 5 3 5 Cervical discogenic rad i cu lopathy, case study, 880, 880-88 1 Cervical fusion, 927-92 8 Cervical kyphotic an talgia, M cKenzie approach for, 343-345, 343-34 6 Cervical m uscles, posterior, post-isometri c relax ation for, 434-436, 434-436 Cervical nerve root pai n , 1 3 2- 1 3 3 , 1 32 l Cervical spi n a l pai n syndrome, 1 34

950

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Index

Cervical spine flex i b i l i ty/mobi l i ty test for, 2 3 8-2 39, 238-239 locomotor function development, 5 5 0-5 5 1 motor control of, 592-5 95 neck condi tions (See Neck con d i tions) surgery on, 926 Cervi co-cranial flexion test, 872, 8 72 Cervico-cranial flexion test of Jul l , 2 50-2 52 , 25 1 Cervicot horac ic junction, fascias, soft t i ssue m anipulation o f, 394-3 9 5 , 3 95 Cha i n reaction(s) B rLigger's approach to, 7 80-78 1 , 78 1- 782 coac tivation patterns i n , 780 i n deep t ru n k stab i l i zers , 7 8 5-78 8 , 785-788, 7 8 5 t food i n take, 789 forward d rawn posture, 782-7 8 3 , 783, 784t of gaspi ng, 789 key li nks and, 790-79 1 kine t i c chain, 76 1 , 76 1 t locomotor system C2-3: levator, 492, 4 93 CO- I : SCM scalene pattern, 49 1 -492, 492 stance phase, 49 1 , 4 9 1 swing phase of gai t , 49 1 , 492 nocicept ive c h a i n , 7 8 3-7 84, 784t pelvic obliqu i ty, 7 9 1 -796, 792- 796 of restricted t ru n k rotation, 789 thorax l i ft w h i l e breathi ng, 788-789, 789 visceral, 789-790 Cha ir, ri sing from, 304, 306 Change readi ness to, i n active care, 3 1 8 social-cogn i t ive theory o f, 7 5 7 Chaos Theory, 895-896 Chin tuck exercise, 6 3 7 , 63 7 Chron ic Pai n Grading Scale, 7 5 5 , 756 Chron ic pai n managemen t , 929 Chronic phase of care, 1 8 5 (See also Chroni c i ty) Chronic spinal pain syndrome, 1 3 3- 1 34 cervical, 1 34 Chronici ty assessmen t of, 1 8 8- 1 95 grad ing system [or, 1 88 , 1 89t Waddell non-organic l ow back p a i n s igns, 1 89-195 , 1 92- 1 94 fac tors t hat i n fl uence, 1 84 , 1 84 t of low bac k pai n , 5 2 risk factors for, 1 34, 1 34 t , 1 84- 1 8 7 fear-avoi dance beli efs, 1 87 neck cond i t ions, 187, 1 88 t by phase o f care, 1 84- 1 85 , 1 85 psyc hosocial fac tors, 1 8 5- 1 87 yel low flags and, 59, 60t, 1 84 (See also Yellow flags) Civil R ights Act of 1 964, 2 80 Clam shell exercise, 65 1 , 653

Classification categories McKenzie approach , 1 3 1 - 1 3 2 treatment-based, 1 32 , 1 3 2t C l i n ical framework cont inuum of care, 763t coping strategies, 754 evidenced-based, 754 functional s tatus, 7 5 5 goals of care, 763t key l i nks, 76 1 -763 sel f-care prescri ptions, 754 7 Rs, 772, 773t SMART outcomes, 754, 754t C l i n i cal practice guideli nes (See Practice gui de l i n es) CO- I : SCM scalene pattern, 49 1 -492, 492 Coactivation of agoni st-antagonist muscles muscle i m balance and, 3 5-36 role in spine stab i l i ty, 3 3-34 patterns i n c h a i n reactions, 780 Cog wheel model of joi n t centration in posture, 3 7-3 8 , 3� 30 1 , 302, 3 5 3 , 353, 78 1 , 782 Cogni t i ve-behavioral components, i n decondi t ion i n g syndrome, 1 3- 1 5 Cogni t ive behavioral therapy, 74 1 -747 i n active care, 3 1 7-32 1 group i n tervention, 3 1 9-32 1 , 3 2 0 t , 744-746, 745t motivation and, 3 1 8 neurophysiological aspec ts i n , 32 1 to pai n m anagemen t , 929 patien t-centered counseli ng, 3 1 8 poten tial problems, 746-747 programs for, 742 psychological risk factors and, 743-744 readi n ess to change and, 3 1 8 sel f-efficacy and, 3 1 8 strategies for change, 744-745 theories about , 3 1 7-3 1 8 Cogni t i ve stage, of motor learn i ng, 596 Col l i s hori zont al reaction, 5 3 2 , 532 Comparative diagnosti c blocks, 1 J 6 Comp l i ance issues active care and, 322-3 2 3 , 3 2 3 t i n isoton ic trai n i ng, 6 7 0 Comp licated cases, advanced di agnostic s teps, 9 1 7-9 1 9 , 9 1 8t Compression fracture, spinal pai n related to, 1 29 t , 1 30 i n elderly, 1 3 5 Concurre n t val idity, 1 48 Confidence i n tervals, 1 48 Con n e c t ive t issue, soft t issue mani pulation of, 39 1 , 39/ Construct val i d i ty, 1 48 Con tent val idi ty, 1 48

Index

Con ti nuum of care, 763t Con tract-relax, 4 1 0 Con tract-relax an tagonist con traction (CRAC), 4 1 8 Con tracture, 5 3 3 BrLigger defi n i tion, 3 5 3 Coordination, i n l o w back pai n , 1 2 Cop i ng strategies, in evidenced-based pract i ce, 754 Core, defined, 7 1 3 Core resis tance exercises, 60, 660 Core tra i n i ng, 7 1 2-7 1 7 example program , 7 1 8 t guidel in es for, 7 1 5 , 7 1 6t , 7 1 7 ki netic chain i mbalance, 7 1 4-7 1 5 , 7 1 5 overvi ew, 7 1 3 postural considerat ions, 7 1 4- 7 1 5 power, 7 1 7 , 723-726 stabi l i zation, 7 1 7 strengt h, 7 1 7 , 7 1 9-723 trai n i ng concepts, 7 1 3-7 1 4, 7 1 4 Correlation coe ffic ient i n t ra-class, 1 47 Pearson's, 1 47 Cort i cope tal nociceptive transm ission , 40, 43 Corticosteroids i njection, 925 oral , 92 1 Costovertebral joi n t blocks, 924 Covered enti ty, American with D isabi l i ties Act defini tion, 2 8 1 Cox-2 i n h i b i tors, 920-92 1 Cranio-cervical flexion test, 1 3 Craniocervical region, m a n i pulation of, 494-497, 495-497 Craniodorsal region, manipulation of, 497-498, 498-4 99 Cri terion vali d i ty, 1 48 Croft i ndex, 1 5 6- 1 5 7 Cronbach's alpha, 1 48 Crossed extension reflex, 5 3 7 , 53 7 Crossed syndrome lower, 40, 42, 205, 206, 2 1 7 , 803, 805, 805-806 u ppeG40, 4� 2 0 5 , 20� 858-860, 859t CT scan, i n diagnostic triage, 1 3 7- 1 3 8 , 1 3 7t Cu ff test, 249-250, 250 Cumulat ive trauma, i n spinal i njury, 34, 34-3 5 , 35, 301 Curl down exercise, 6 73-6 74 Curl-ups fu nctional stabi l i ty tra i n i ng, 630, 630 with medicine bal l , 7 1 0, 7 1 0 movement pattern test, 2 1 4-2 1 5 , 2 1 5 stabi l i zation exercise, 1 05 , 1 06 , 1 0 7 Daily activities, react i vation advice about , 303-304, 306-3 1 3, 307, 3 1 1 Dead bug exerc ise, 627, 627-62 9, 629, 7 70 Dead l irt , i n fTee-weight tra i ning, 707-708, 708

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951

Decondi tioni ng defined, 7 pain and, 4 Decondi ti o n i ng syndrome affects of i mmobil i zation, 1 5, 1 5- 1 6 , 1 6 cogn i t i ve-behavioral compon e n ts i n , 1 3- 1 5 function and performance, 7- 1 1 low back pai n and, 1 1 - 1 3 , 1 3- 1 5 Deep diaphragm a t i c breath i ng, 382 Deep neck f lexors, motor con trol o r, 5 92-594 Deep t i ssue massage, 4 1 3 Deep t runk stab i l i zers, chain of, 7 8 5-78 8 , 785- 788, 785t Derangement syndrome, 3 3 5-340, 8 0 3 anterior, 3 3 9-340 pathoanatomical explana t i o n , 3 3 7-340 phenomenological pattern , 3 3 5-3 3 7 posterior, 3 3 7-3 3 8 relevant posterolatera l , 3 3 8-3 3 9 subtypes, 3 36-3 3 7 Descend ing pain pathway, 75 Developmen t of l ocomotor [-unction, 5 3 1 -5 5 2 cervi cal region, 5 5 0-5 5 1 4 . 5 months, 540-542 , 54 1 four t h through sixth week, 538, 5 3 8-539 functional joi n t cen tration, 5 3 5 lumbar regi on, 5 5 1 neonatal stage, 536, 5 3 6-5 38 phasic muscles i n , 543-5 50 postural ontogenesis, 5 34-5 3 5 reflex locomotion, 542-543, 543-544 thoraci c region, 5 5 0-5 5 1 3.5 months, 5 3 9-540, 540 tonic m uscles i n , 545-548 D iagnost i c blocks, 1 1 5- 1 1 6 , 9 1 8-9 1 9 advantages of, 1 1 5 comparative, 1 1 6 face vali d i ty of, 1 1 5 sacro i li ac joint, 1 1 5 target spec i fi c i ty of, 1 1 5 use of con troIs and, 1 1 5- 1 1 6 vs. discography, 1 1 5 zygapophysial joint, 1 1 5 D i agnostic i magi ng, overem p hasis o n , 74, 76, 76-77 D i agnostic procedures, evaluation of, 6, 6t D iagnostic t ri age, 1 25-1 44 algori t h m for, 8 1, 1 2 6, 1 2 7 biopsychosocial model and, 80-8 7 c l assi ficati o n system i n , 4 d i agnosti c labels, 1 3 6 diagnosti c tests, 1 37- 1 42 bone scan , 1 3 8- 1 39 , 1 3 8 t C T scan, 1 3 7- 1 3 8, 1 3 7t d iscography, 1 3 9- 1 42 electromyography, 1 3 9, 1 39 t M R I , 1 3 8 , 1 3 8, 1 3 8 t radiography, 1 3 7 , 1 3 7 t

952

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Index

D i agnostic triage (contd.) for l ow bac k pai n , 799, 799t, 800t for neck cond i tions, 8 5 3-854 pat i e n t i n j eopardy, 1 3 3- 1 34 red flags, 4 , 8 2 , 8 2 t , 83, 1 26- 1 27 , 2 2 7 si mple backache vs. nerve root problems, 1 3 1 - 1 3 3 s i n is ter cond i tions, 1 2 8 - 1 3 1 , 1 29t cauda equ i n a syndrome, 1 30 mal ignancy, 12 8 , 1 2 9t progressive neurologic loss, 1 3 0- 1 3 1 spinal [Tactures, 1 30 spine i n fection, 1 2 8- 1 30 spondyloarthropathy, 1 3 1 spec ial populations, 1 3 5- 1 36 yellow flags, 5 , 8 2 , 1 2 7- 1 2 8 Diaphragm in breathing, 5 5 3 , 568 i n postu ral on togenesis, 5 5 1 role in resp i ration, 3 7 1 Diaphragmatic trigger poi nts, 380 Direct t h reat, Ameri can with D isabil i t i es Act defin i tion, 2 8 1 Di sabi l i ty American with D isabi l i t i es Act defini ti o n , 2 8 1 assessment o f, 9 assoc iated w i t h chronic spinal pai n syndrome, 1 3 3- 1 34 con t i nuum of, 9, 10 defi ned, 1 5 3 low back pa i n and, 5 5 , 5 5 t role of pai n i n , 9- 1 0, 1 1 vs. i m pairment, 8 , 1 5 3 Disc annulus, damage to, 97 Disc nucleus, damage to, 97-98 Di scography, 1 3 9- 1 40, 1 40, 9 1 8-9 1 9 advantages o f, 1 1 5 in diagnosis of i n ternal disc disruption, 1 1 6- 1 1 7 false-pos i t ive tes t , 1 1 6 in findi ng, 1 1 6-1 1 7 goal of, 1 3 9- 1 40 pai n related to, 1 40, 1 40 pos i t i ve tes t , 1 1 6 provocation, 1 1 6- 1 1 7 sacro i l i ac j o i n t , 1 40- 1 4 1 vs. d i agnostic blocks, 1 1 5 zygapophseal j o i n t , 1 4 1 - 1 42 Discrimi nation American with D isabi l i t i es Act and, 2 8 1 in e m ployment selection, 2 7 9 Dislocation, neck condi t ions rel ated to, 8 5 3 D i s t a l gai t , 2 2 1 Distrac tion, i n Waddell non-organ i c low back pain signs, 1 9 1 - 1 93 , 1 93 Di sturb i ng fac tor, Brugger d e fi ni tion, 3 5 3 Doctor/patient rel ationship, 8 89-897 environment i n , 890, 8 9 1

Hawthorne effect , 892 hea l t h promotion, 893-894 i ndividual i n , 890 i nteraction i n , 892 l istening skil ls , 89 1 managi ng m u l t i pl e problems, 89 1 -892 obta i n i n g patient's confidence, 892 patient educat ion, 894 pat i e n t's self-respect i n , 893 scope of, 890 spiri tual factors , 895-896 symbols and metaphors i n , 893 use of fitness center, 894 use of spandex body sui t , 894-895 Dorsal raise exerc ise, 6 78 Dysfunction syndrome, 3 3 3-3 3 5 , 802 c l i nical i nterve n t ion, 3 34-3 3 5 , 335, 3 3 5 t pathoanatomi cal explanation , 3 3 4 phenomenological pat tern , 3 3 3-334 Elbow, epicondylar pai n , soft t i ssue man ipulation for, 397, 398 Elderly, 898-908 con d i tions associated with hip osteoart h ri t i s , 90 1 -902 knee osteoart hri tis, 900-90 1 osteoporosis, 900 spinal stenosis, 904-906 total h i p replaceme n t , 902, 902 l total knee art h roplasty, 90 1 , 90 1 t considerations i n diagnostic triage, 1 3 5 exercise and benefits rel ated to, 899-900 i n i t i a t i ng program, 907-908 risks related to, 900 exertional risk assessments for, 906-907 fall prevention i n , 903 fra i l ty i n , 903-904 E lectromyography ( E M G ) i n analysis o f physical performance test battery, 268-269, 2 7 1-2 72 i n d i agnosti c triage, 1 39 , 1 39t Employer, American with Disab i l i t ies Ac t defini tion, 2 8 1 Employment screeni ng American with D isabi l i t i es Act and, 2 7 8 , 280-28\, 2 80-28 2 development of test i ng procedures, 284 Equal Employment Opportun i t ies (EEO) laws and, 278�279 fitness for duty screening, 278-2 79, 282-2 83 functional capac i ty evaluation , 2 89-290 by health care professionals, 2 8 5 other laws related t o , 2 8 0 pre-placement screen i ng, 2 8 3-285

Index

return to work screening evaluat ing physician's role, 2 8 8-2 89 trea t i ng physician's role, 2 85-2 8 8 , 2 8 6 t val i d i ty of, 2 7 7-2 7 8 E ndplates, damage t o , 97 Endurance, i n low back pai n , 1 2 , 57 Endurance tests (See Strength/endurance tests) Endurance train i ng, in [-unctional stabi l i ty train ing, 615 Epicondylar pain chain of, 789 soft tissue manipulation for, 397, 398 Epidural steroid i njections, 924-925 Equal Employmen t Opport u n ities (EEO) l aws, employment scree n i ng and, 2 7 8-279 Equ il i briu m, in whole body stabi lity, 3 1 Erector spi nae hypertrophy, 2 1 7-2 1 8 , 2 1 8 post-isometric relaxation for, 430, 432-43 3 , 432-434 tigh t ness, eva l uation of, 2 1 1 , 213, 2 3 6 , 236 Ergonomic workstation advice, 302-303, 303 chai r, 302 checkl ist for, 305t desk, 302-303 mini-breaks, 300-302, 301, 302 sitting position, 302, 303-304 Essential fu nctions, American w i t h D isab i l i ties Act defin ition, 2 8 1 Evidenced-based hea l thcare, 60-65 defined, 60-6 1 improvement of, 65 l i m i tations of, 64 for low back pai n , 6 1 -63 for musculoskeletal disorders, 754-7 5 5 for neuro-musculoskeletal care, 7 72-7 73 physician behavior and, 63-64 Execu t ive Order 1 1 246 ( 1 965), 280 Exercise, back extensions, 636 Exercises, 620t overview, 64 1 t Exercise(s) for elderly benefits related to, 899-900 i n i t i a t i ng program , 907-908 risks related to, 900 role in acute low back pai n , 1 8- 1 9 role i n chron ic, 20, 20t role i n su bacu te low back pai n , 1 9-20 Exertional risk assessments, for elderly, 906-907 Exteroceptive therapy, 403-406 individual perception and, 406 modifying tac t i le perception, 404 for scar sensi tivity, 404-405 sel f therapy, 406 tacti le perception assessment, 403-404 Extrem i ties, fascia, soft tissue manipulation of, 396

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953

Face val idi ty, 1 48 Facet joint blocks, 92 3-924 Facet syndrome, case study, 840, 840-843 Fac i l itated segmen t, 42, 44 Fall prevention, i n elderly, 903 Fascias dysfunctional, 392 function of, 392 soft tissue manipulation of, 3 92-396 Ach i l les tendon, 396, 3 9 7 back, 3 92-394 , 3 93 buttocks, 394, 3 94 extre m it ies, 396 heel, 396, 3 96, 3 9 7 neck, 3 94-3 9 5 , 3 95 scalp, 396 thoraci c , 394, 3 95 Fatty acids (See also Omega-6 fatty acids) types of, 7 3 3 Fear-avoidance bel iefs , 1 4 abnormal i l l ness behavior a n d , 80, 80 active care and, 296-297 chronicity and, 1 87 i n decond i t io n i ng syndrome, 1 3- 15 i m pact on performance, 1 3- 1 4 low back pain risk and, 5 7 Feed-forward mechani s m , i n motor control, 5 8 8-589, 589 Feedback, in motor l earni ng, 596 Feedback mechanism, in motor con tro l , 5 8 8-5 89, 589 Femoral nerve stretch test (FNST), 472, 4 73-4 75, 474t F ibromyalgia, central sensi ti zation and, 44 F inger flexors agistic-eccentric con traction approach for, 3 5 7-3 5 8 , 358 Thera-Band exercise for, 363 F itness, component s of, 690-6 9 1 , 690t F i tness center, in doctor/patient relationship, 894 F i tness for duty scree n i ng, 2 7 8-279, 2 82-2 83 Flex i b il i ty, i n low back pain , 5 7-58 Flex i b i l i ty/mobility tests, 2 3 0-240, 2 3 1 t a n kle, 2 3 1 -2 3 2 , 23 1-232 cervical s p i ne, 2 3 8-2 39, 238-239 hip, 2 3 2-234, 233-235 knee, 2 3 2 , 232 l u m bar spine, 2 3 4-2 3 6 , 236-23 7, 2 3 8 shoulder, 2 3 9-240 Flexion-extension stretch, 1 06, 1 0 7 Flexion-relaxation phenomena, i n low back pai n , 1 1 Floor effects, of ou tcome assessment too l , 1 49 Food i ntake, chain of, 789 Foot retrocapital support of the, 3 65-366, 366 tac t i le perception of, 405 For low back pain, overview, 806t

954

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Index

Forward drawn posture, chain reaction, 7 82-783, 783, 784t Fracture neck cond i t ions related to, 853 spinal pai n related to, 1 29 t, 1 30 Fra i l ty, in elderly, 903-904 Free radi cals, i n fl ammation and, 7 3 2-733 Free-weight tra i n ing, 703-708 barbell l unge, 6 9 7, 705-706 barbell row, 704, 704 dead l ift, 707-708, 708 dumbbel l row, 704, 704-705 for explosive power, 706 good morn i ng, 6 95, 705 hang clean, 706, 706-707 overview, 703 power clean, 707, 70 7 special concerns, 703 squat, 705, 705 Funct ional approach, 7 77-77 9 advanced d i agnostic steps, 9 1 7-9 1 9, 9 1 8t basic pri nci ples, 9 1 6-9 1 7 Functional assessmen t methods, 260-2 72 physical performance test battery, 262-2 72 self-reports, 26 1 -262 (See also Outcome assess ment) Functional Assessmen t Scale ( FAS), for l ower extremi ty, 1 58, 1 77 Functi onal capaci ty assessme n t, 7-8, 1 0 for return t o working screening, 2 89-290 decondi t i o n i ng and, 7 impairment vs. disab i l i ty, 7-8, 8 t Functional disab i l i ty, assessment of, 1 50t, 1 5 3- 1 59 Functional exami nation, goals of, 76 1 , 76 1 t Fu nctional Index Questionnaire (FIQ), for knee, 1 58 Functional i n tegrated t ra i n i ng ( FIT), 64 1 -660, 760, 764t, 770- 7 7 1 core resi s tance, 60, 660 funct ional reach, 65 1 , 65 1-652 lu nge, 649, 649-650 overview, 64 1 , 64 1 t pulley, 654, 655-659 sensory-motor trai n ing, 642-643, 642-644 squat, 645, 646-648 Fu nctional joint cen tration, 5 3 5 Fu nctional pathology, 7 7 7 Functional reach exercises, 65 1 , 65 1-652 Functional scree n i ng exercises overview, 763, 764 pal l iative, 768 spine-sparing, 768, 76 9 spi ne-stab i l i z i ng, 769-771 Functional screen i ng tests of cervical spi ne, 860-86 1 , 86 1 t

arm abduction test, 868, 868-869 cervi co-cranial flexion test, 872, 8 72 Janda's neck flexion test, 8 70, 8 70-87 1 orofacial coordination test, 8 72-873, 8 72-873 push-ups, 866, 866-86 7 respiration assessment, 862, 862-863 wall angel, 864, 864-865 for l ow back pai n, 806-828, 807-829 arm abduction test, 76 7 h i p i nternal rotation mob i l i ty test, 765 Janda's h i p abduction test, 766, 822, 822-823 Janda's h i p extension test, 766, 824, 824-825 J anda's t ru n k flexor test, 766, 830, 830-83 1 l unges, 765, 8 1 6, 8 1 6-8 1 7 modified Thomas test, 765, 8 1 8, 8 / 8-8 1 9 mouth ope n i ng test, 76 7 one-leg squat, 765, 8 1 4, 8 / 4-8 1 5 one-leg standing balance, 764, 807, 807-809 overview, 763, 763 push ups, 76 7 side bridge endurance test, 766, 826-827, 826-82 7 trunk extensor endurance test, 766, 8 2 8, 828-829 trunk flexor endurance test, 766, 832 two-leg squat, 764, 8 1 2, 8 1 2-8 / 3 Vele's reflex stabi l i ty test, 764, 8 1 0, 8 / 0-8 1 / Vleemi ng's active and resisted S L R test, 765, 820, 820-82 1 wall angel, 76 7 Functional stab i l i ty traini ng, 6 1 2-66 1 effect iveness of. 6 1 4 endurance trai n i ng in, 6 1 5 exercises, 6 1 9-640, 620t back extensions, 635, 636 b i rd dog, 623, 623-624 braci ng, 622 bridge, 63 1 , 632 cat camel, 62 1 , 62 1 t core resistance, 60, 660 curl - u p, 630, 630 dead bug, 627, 62 7-629, 629 functional i ntegrated tra i n i ng (FIT), 64 1 -660 functional reach, 65 1 , 65 1-652 hamstring curls, 633, 634 l unge, 649, 649-650 overview, 6 1 9, 64 1 , 64 1 t pulley, 654, 655-659 push-up, 639,639-640 sensory-motor tra i n ing, 642-643, 642-644 side bridge, 625, 625-626 sphi nx, 637, 63 7 squat, 645, 646-648 stabil i ty tra i n i ng, 619-640 wall angel, 638, 638 motor learni ng in, 6 1 7-6 1 8 progression for, 6 1 7-6 1 9, 6 1 8 t psychology of, 6 1 5-6 1 6

Index

safety of, 6 1 4 start i ng poi nt for, 6 1 6-6 1 7, 6 1 7t training specificity and, 6 1 4-6 1 5 Functional status, parameters of, 755 Functional tapi ng, in Bti.igger method, 3 66, 366 Gaenslen test, 1 4 1 Gait analysis chai n reactions, 49 1 , 492 distal, 22 1 ground reac tion forces and, 268-269, 269 with low back pai n, 268-269 movements in, 22 1 for muscular imbalance, 207, 220, 220-2 2 1 one-leg standi ng test, 220, 2 2 1 in physi cal performance test battery, 268-269, 269-2 72 proximal, 220 swi ng phase of, 49 1 , 492 Gasping, chain of, 789 Gastrocnemius post-isometric relaxation for, 448-449, 449 Lightness, evaluation of, 2 ] 2, 213, 2 3 1 , 23 1 Gender, in physical performance test battery, 266-267 General health, assessment of, 1 50t, 1 52 - 1 53, 1 52 t Gilelle's test , 80 I Gi lJet test, 1 4 1 G i l l's exertional risk assessment for elderly, 907 G lenohumeral joint, manipulation of, 502, 503 Global I m pression of Change questionnai re, 1 69 Global muscle stab i l i zation trai n i ng (See Isotonic training) Gluteus maximus i n h i bi tion 115. weakness, 2 2 1 Gluteus maxi mus, post-isometric relaxation for, 429, 429 Gluteus medius i n hibi tion 115. weakness, 2 2 2 manual resistance techniques for, 456, 457 Good morni ng, in weight-train i ng, 6 95, 705 G raded exposures tra i n i ng ( GET), 6 1 5-6 1 6 Great diagnostic muscle loop, Bri.igger method, 353, 353 Grip strength, strengt h/endurance test for, 2 4 7, 247-248 Ground reaction forces, gait analysi s and, 268-269, 269 Guideli nes, practice (See Practice guideli nes) Gynecological conditions, chain reaction and, 790 Hamstring curls exercise, 633, 634, 770 Hamstri ngs evaluation of t igh tness, 209-2 1 0, 21 J, 2 3 2-233, 233 post-isometric relaxation for, 4 1 9-420, 4 1 9-42 J

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955

Hand Function Sort ( HFS), 1 5 7 H ands, tac t i l e perception o f, 405 Hang clean, i n free-weight trai n i n g, 706, 706-707 H arris H i p Score, 1 5 8 H arvard method, for aerobic fi t n ess eva l uati on, 2 52-2 5 3 Hawthorne effect, 8 9 2 Head flexion, movement patte rn test, 2 1 6, 216 Healing, spiri tual factors i n, 895-896 H ealth Care Act of 1 973, 2 80 Health Care Needs Assessment, 9 3 5 H e a l t h promotion, i n doctor/patient relationship, 893-894 Heal t h Technol ogy Assessment exercise, 9 3 5 H eart problems chain reaction and, 789-790 exertional risk assessmen ts for, 906-907, 906-907 H eel, fascia, soft tissue manipulation o f, 3 96, 3 96, 397 Heel reflex, 5 3 7-538, 538 Herniated disc diagnostic i maging for, 76-77 spinal pai n related to, 1 29t surgery for, 78-79, 79t Hip flexibili ty/mobi l i ty tests of, 2 32-2 34, 233-235 ou tcome assessment for, ] 5 8 post-isometric relaxation [or, 45 1 , 451 H i p abduction test, J anda's, 766, 822, 822-823 H i p abductors, movement pat tern test, 2 1 4, 215 H i p adductors post-isometric relaxation for, 420-422, 422-423 tightness, evaluation of, 208, 210 H i p capsular mobi l i zation anterior, neuromobil i zation tec h n iques, 472, 4 74 posterior, neuromobil i zation tec h n iques, 470, 4 70 H i p extension test, Janda's, 766, 824, 824-825 H i p flexion, flex i b i l i ty/mobi l i ty test for, 2 3 2-2 33, 233 H i p flexors, tightness, evaluation of, 208, 209 H i p h i nge, in weigh t-train i ng, 694, 694t, 6 95 H i p ( hyper)extension, evaluation o f, 2 1 4, 214, 2 2 1 , 233, 2 3 3-234 Hip i nternal rotation mobil i ty test, 765 H i p joint, manipulation of, 5 05, 507 H i p osteoarthri tis, 90 1 -902 H i p replacement, 902, 902t H i p rotation, flexi b i l i ty/mobi l i ty test for, 2 3 4, 235 H i p rotators agistic-eccentric contraction procedure for, 360, 360 Thera-Band exercise for, 364 H IV i nfec tion, spinal pai n related to, 1 28 H old-relax, 4 1 0-4 1 1 Holistic approach, 779 H o t rol l use, in Bnigger met hod, 3 5 7, 357

956

--

Index

Hyperalgesia, 40, 729 Hyperalgesic (skin) zone, 3 90-39 1 Hypermobi l i ty, of muscles, 2 2 2, 222-224 Hypertonus causes of, 5 3 3 cen t ral nervous system i n, 5 3 2-533 muscles, 783 types of, 4 1 ] -4 1 2 , 4 1 H Hypotonus muscles, 783 Hysteresis, 30 1 , 3 0 1 I m mobi l i za t i on, affects of, 1 5, 1 5- 1 6, 1 6 I m pairment assessmen t o f, 8 con t i nuum o f, 9, 1 0 role o f pain i n , 9- 1 0, 1 1 VS. disabi l i ty, 7-8, 8 t , 1 5 3 Implan table therapies, for pain, 929 I ndependent Medical Evaluator, 2 8 8-2 89 I n fec tion neck condi t i ons rel a ted to, 854 of spine postopera t ive, 1 3 5 spinal pain related to, 1 2 8- 1 30 I n nammat ion foods t hat cause, 730t free rad icals and, 7 3 2-733 i ns u l i n resistance and, 7 3 1 -7 3 2 omega-6 fatty acids and, 7 33-734, 7 3 4 t pai n and, 729-73 1 , 7 3 0 t potassium and magnesium for, 7 3 5-7 36, 7 3 6 t I n fTaspinat us, post-isometri c relaxation for, 447, 447-448 I njections, 923-925 epidural s teroids, 924-925 joi nt blocks, 92 3-924 post-i njec t i on care, 925 rh izotomy, 924 t rigger poi n t , 923 Instabi li ty spinal pai n and, 1 1 7 t i ssue damage and, 98-99 Inst i t u te for t h e Advancemen t of H uman Behavior, 896 I nsu l i n res istance, i nllammation and, 7 3 1 -732 I n tell igent Design M ovement, 895 I n ternal disc dis ruption (IDD) di scography in diagnosis of, 1 1 6- 1 1 7 spinal pai n related to, ] 1 6- 1 1 7 , 1 1 8 I n ternational Classification of Functioni ng, D isab i l ity, a n d Health ( I CF), 7-8, 1 0, 2 2 7 I n terna t ional Knee Documentation Com m i ttee Subject ive Knee Form, 1 5 8 I n terna t ional Qual i ty of Life Assessment ( I QOL A), 1 5 2- 1 5 3 I nt erneuron dys function, 4 1 2

Interobserver rel iabili ty, 1 48 I ntra-abdom inal condi tions, spinal pain related to, 131 I n tra-class correlation coefficient, 1 47 I ntra observer reliabili ty, 1 48 I n t radiscal electrothermal t herapy, 929 Intradiscal nuclear derangement model, 3 3 7-340 Isokinetic strength, i n low back pai n , 1 1 Isometric t ru n k extensor endurance tes t , 246, 24 7 Isometric tru n k flexor endurance test , 243-244, 244t Isotonic trai n i ng, 667-685, 683t advantages of, 670-67 1 assessment for, 68 1 -682 case studies, 684-685 concurre n t passive care, 684 dosage, 669-670 duration, 670 endurance range, 672t exclusion cri teria, 680-68 1 exercises, 6 7 2 , 6 73-6 79, -674, 678 back l i fts, 6 73 curl downs, 6 73-6 74 dorsal raises, 6 78 gym ball squats, 6 75 leg abduction, 6 76 leg adduction, 6 76 leg extensions, 6 74-6 75 l eg raises, 6 79 neck mac h ine, 6 77 pull-downs, 6 76 reverse fly, 6 78 side l ifts, 6 75 supine fly, 6 78 factors for successful, 669 global stabi l i zation, 669 local s tabi l i zation, 668-669 pat i e n t selection, 678-680 prescription for, 682-684 ratio promotion, 67 1 reassessment, 684 s tages of, 672, 674, 678 supervision and com pl iance, 670, 680 task-specific , 67 1 -672 Ito's tru n k extensor endurance test, 246-247, 247t Janda's hip abduction test, 766 Janda's h i p extension test, 766, 824, 824-825 Janda's neck flexion test, 870, 8 70-87 1 Janda's trun k flexor test, 766 Job satisfac t ion, assessmen t of, 1 6 1 Joint blocks, 923-924 costovertebral, 924 facet, 92 3-924 sacroi l iac, 924 J o i n t cent ration, functional, 535

Index

Joi n t in flammation, neuronal events i n , 39, 4 1 Joint manipulation (See M anipulation) Joi n t mobil i zation post-isometric relaxation (PIR), 45 1 -453, 45 1-455 vs. joint man ipulation, 488 Joint replacement hip, 902 , 902t knee, 90 1 , 90 1 t Joi nt signs, 489 Jull, cervico-cranial flexion test of, 250-25 2, 251 Jumps, i n sensory motor stimulation, 5 24, 525 Kenny, Sister, gluteus medius faci li tation, 456, 45 7 Key link(s) chain reacti ons and, 790-79 1 criteria for, 790 6nding, 76 1 -763 Kidney di sease, c hain reaction and, 790 Kinesiotaping muscle re-educaLion and, 664-665 for pelvic crossed syndrome, 665, 665 techn iques for, 664, 664 [or upper crossed syndrome, 665, 665-666 Kinesiotex, 663-664 Kinetic chain, 76 ] , 76 1 t Kinetic chain imbalance, 7]4-7 1 5, 7 1 5 Knee flexi bili ty/mobility test of, 2 3 2 , 232 outcome assessment for, 1 5 8 Knee art h roplasty, 90 1 , 90 I t Knee osteoart hritis, 900-90 1 Knee to chest stretc h , 3 1 5 Kyphotic antalgia cervical , McKenzie approach for, 343-345, 343-346 lumbar descri ption of, 334, 334, 3 3 7 M c Kenzie approach for, 340-343, 340-343 Lateral pul l-down, machine exercise, 697-698, 698 Latissimus dors i , neuromobi lization tec h n i que, 48 1 , 4 8 1 Layer (stratification) syndrome, 40, 43, 2 06,207 Leg abduction exercise, 6 76 Leg adduc Lion exercise, 6 76 Leg extensions isoton ic training, 6 74-675 as stabi l ization exercises, 1 06 , 1 08, 6 2 3 , 623-624 Leg length di fference, 79 1 -796, 792-796 Leg pain c l inical course, 56 in diagnostic tri age, 1 32 nerve root compression due to herniation, case study, 837-839, 83 7-839 nerve root compression due to spinal s tenosis, case st udy, 844, 844-845

--

957

Leg raise exercise, 6 79 in plyometrics, 7 1 0, 7 1 0-7 1 1 straight to evaluate h i p flexion, 2 3 2-233,233 neuromobilization technique, 468, 468-469, 470-47 ] in Waddell non-organ ic low back pain signs, 1 92, 1 93 Levator A n i , yoga-based exercises for, 5 8 2 Levator scapula neuromobilization techn ique, 479-480, 480 post-isometric relaxation for, 43 7-439, 438-439 tightness, evaluation of, 205,205, 207, 2 1 6 , 2 1 7 Li ft i ng McGill 's rule for, 3 1 1 , 3 1 3-3 ] 4, 314t reactivation advice abou t , 3] 1 , 3 1 3-3 1 4, 3 1 4, 3 1 4 t L i fting capaci ty, i n low back pain, 5 7 Ligament sprain, spinal pain related t o , ] 1 7 Ligaments, damage to, 98 Liliopsoas, post-isometric relaxation for, 422-425, 424-425 Limbic system dysfunction, 4 1 1 Listeni ng skills, in doc tor/patient relationship, 89 1 Loaded reach , in physical performance test batlery, 2 6 3 t, 264, 2 7 1 -272,2 73 Locomotor function, development of, 53 1 -5 5 2 cervical region , 550-5 5 ] 4.5 mont h s , 540-542,54 1 fourth t hrough sixth week, 538, 5 3 8-539 functional joi n t centration, 535 l umbar region , 55 1 neonatal stage, 536, 5 3 6-5 3 8 p h asic muscles i n, 543-5 50 postural ontogenesis, 534-53 5 reflex locomotion, 542-543,543-544 t horacic region, 5 5 0-55 1 3.5 months, 539-540, 540 tonic muscl es i n , 545-548 Locomotor system chain reactions, 49 1 -492, 49 1-493 key l i n ks, 492-493 reflex nature of, 490-493 tension pain relati o ns h i p , 489 Longitudinal validity, ] 48 Lordot i c antalgia, description of, 3 3 7 , 350 Low back pai n acute biopsychosocial model , 8 7 evi denced-based heal t hcare, 6 3 risk factors for, 56-5 9 case study, 840, 840-843 chron ic evidenced-based hea l t hcare, 63 yell ow f lags for, 59, 60t chron i c i ty of, 5 2, 59-60 c lassification of

958

-

Index

Low back pai n, classi fication of (contd.) active l i m b movement, 803, 804 Canadian Back I nstitute, 803 M c Kenzie, 802-803 U n iversity of P i t tsburg, 799-800, 800t, 801-802, 802 cl ini cal course, 53, 53-55, 54t costs of, 55, SSt, 56 decond i tioning syndrome, 1 1 - 1 3 diagnostic dilemma i n , 4-6 diagnostic triage, 799, 799t, 800t f-tmctional screen , 803-8 3 5 , 8 0 3 t gai t analysis w i th , 2 68-2 69 i ncidence, 5 2-53 lower crossed syndrome, 803, 805, 805-806 motor con trol changes i n, 590-592 , 59 1, 6 1 3-6 1 4 c l i nical assessment, 597-602 motor re-educa tion for, 596-597 movement patterns i n , 2 67-268 nonspeci fi c , 5, 5-6, 7, 227 ou tcome assessment tools for, 1 50t, 1 5 3- 1 55, 1 5 5 t Oswestry Disab i l i ty I ndex ( O D I), revised, 1 53-1 54, 1 70- 1 7 1 ot her, 1 5 5 t Performance Assessment and Capac i ty Testing Spinal Function Sort, 1 54- 1 5 5 Roland-M o rris D isabil i ty Questionnaire ( RDQ), 1 54, 1 72 phase of care, 1 84- 1 85, 1 85 red flags, 799, 799t sou rces of, 1 1 7- 1 1 8 Low bac k pai n assessment tools, 1 50t, 1 5 3 - 1 5 6, 1 5 5t Oswestry Disabil i ty I ndex, 1 5 3- 1 55, 1 5 5t, 1 70-1 7 1 other, 1 5 5t Performance Assessment and Capac i ty Testing Spinal Function Sort, 1 54- 1 5 5 Roland-M orris Di sabi l i ty Questionnaire (RDQ), 1 54, 1 72 Lower c rossed syndrome, 40, 42, 2 05, 206, 2 1 7, 803, 805, 805-806 Lower extre m i ty, outcome assessment for, 1 5 8- 1 59, 1 77- 1 7 8 Lower Extre m i ty Funct ional Scale ( L E FS), 1 5 8- 1 59, 1 78 L u m bar f-usion, 927 Lumbar kyphotic antalgia descri ption of, 3 34, 334, 3 3 7 M c Kenzie approach [or, 340-343, 340-343 L u m bar mul t i fidi anatomy of, 588 assessment of motor con trol, 600-60 1 , 601 post- isometric rel axation for, 433-434, 434 spinal motor con t rol and, 588, 5 8 8-589 Lu m bar nerve root pai n , 1 32, 1 3 2t, 1 3 3 t

Lu mbar spine flex i b i l i ty/mobi l i ty test for, 234-2 3 6 , 236-23 7, 238 locomotor function development, 55 1 low back pai n (See Low back pain) post-isometric rel axation for, 45 1 -452, 45 1-453 surgery on, 92 5-926 L umbar stabi l i ty, 93- 1 09 exercises for, 1 02-1 09, 1 03- 1 08 Lumbosacral region, manipulation of, 502, 503 Lunges, 765, 771, 8 1 6 , 8 1 6-8 1 7 with barbell, 6 9 7, 705-706 for core trai n i ng, 72 1 functional stabi l i ty trai ning, 649, 649-650 in sensory motor stimulation, 522, 523-524 Lysholm Knee Rating Scale, 1 58 Mach i ne exercises, weight-trai ni ng, 697-702 abdomi nal mac h ine, 702, 702 back extension, 699, 6 99, 700 cable crossover, 698, 6 98 l ateral p u l l-down, 697-698, 6 98 low pulley spinal rotation, 70 1 , 70 1 pull ey crunch, 702 , 703 rotary torso machi ne, 70 1 -702, 702 seated rowi ng, 6 96, 699-700 s i ngle arm pulley row, 700, 700-70 1 M agnesium, i n flammation and, 735-736 M a l i g nancy neck conditions related to, 854 spinal pain related to, 1 2 8, 1 29t M a n i pulation, 487-508 barrier p henomenon, 493-494, 494 craniocervical region, 494-497, 495-497 craniodorsal region, 497-498, 498-499 extre m i ty joints, 502, 503-507 joint signs, 489 lum bosacral region, 502, 503 manipu lable lesion, 488-489 post-isometric rel axation ( P I R), 494 provocat ive testing, 489 reflex effects i n, 490-493 side effects of, 489-490, 490t tension pai n relationsh i p , 489 t horacolumbar region , 500-50 1 , 50 1 thrust V5. non-thrust, 488 upper rib joints, 498-500, 500-50 1 115. mobilization, 488 M anual resistance techniques ( M RTs), 407-463 Brugger lower-quarter eccentri c, 450, 4 5 1 Brugger upper-quarter eccentric, 4 5 0 , 45 1 c l i n i cal application, 4 1 2-4 1 4, 4 1 2 t concepts, 408 effect iveness of, 409-4 1 0 fac i l i tation tec h n i ques, 4 5 3 , 455, 456 gluteus medius, 456, 45 7 m iddle trapezius, 45 5-456, 456 scapulo-thoracic, 4 5 3 , 455, 456

Index

i n h i bi tion or tonic muscle chains, 450-45 1 muscle classi fication for, 4 1 1 -4 1 2 , 4 1 1 t neurophys iology of, 408-409 post-fac i l i tation stretch ( PFS), 4 1 7-4 1 8 post-isometric relaxat ion ( P I R), 4 1 0 , 4 1 5-4 1 7 (See also Post-isometric relaxation (PiR)) proprioceptive neuromuscular facil itation, 409 technique pri nciples, 4 1 4-4 1 5 , 4 1 5 Massage, deep t issue, 4 1 3 Mastication , chain or, 789 McGil l 's ru le for l i ft i ng, 3 1 1 , 3 1 3-3 1 4 , 3 1 4t McKenzie approach , 6, 3 3 0-35 1 back extension exerc ise, 768 cervical kyphotic an talgia manageme n t , 343-345, 343-346 cervical torti col l i s antalgia management, 348-349, 348-349 c l i n ical decision making and, 760 coronal antalgia management, 346-349, 346-350 efrectiveness of, 20 on functional stab i l i ty train i ng, 6 1 7 lordotic antalgic management, 349-3 50, 350 low back pai n classi fication, 802-803 lumbar kyphot i c antalgia management , 340-343, 340-343 lumbar scoliotic antalgia managemen t , 346-348, 346-348 range of motion i n , 34-35 return to work predic tors, ] 9 1 syndrome patterns derangement syndrome, 3 3 5-340 dysfunction syndrome, 3 3 3-3 35 postural syndrome, 3 3 ] -3 3 3 treatment classi fications, 6, 1 3 1 - 1 3 2 M echanical sensi tivity, 759 Median nerve bias, upper l i m b neurodynam i c test, 474-476, 4 76, 476t, 478 Medication analgesics, 920 anti-inf]ammatories, 920-92 1 ant iconvulsants, 922 antidepressants, 922 complications of, 9 ] 9, 9 1 9t goals for use, 9 1 9 i njections, 923-925 epidural steroids, 924-925 joint blocks, 92 3-924 post-inject ion care, 925 rh i zotomy, 924 trigger poi n t , 923 muscle relaxants, 92 1 -922 role of, 9 1 9 M edici ne bal l , plyometrics usi ng, 709-7 1 0, 7 1 0 M e n tal Health Component, i n SF-36, 1 5 3 M etabol ic syndrome, 73 1 -7 3 2

--

959

Metacarpals, soft t issue m a n i pulation between, 3 96-397 M etastati c disease, spinal pai n related to, 1 2 8 , 1 29 t Metatarsals, soft t issue man i pulation between , 3 96-397 M icrodiscectomy, 927 M i n i-breaks, ergonomi c workstation advice and, 3 00-302, 301, 302 M i ni m a l detectable c hange ( M D C) score, 1 49 M i nnesota M u l ti p l e Personal i ty I nven tory ( M M PI), 1 86 , 1 9 1 Mob i li t y tests (See Flex i b i l i ty/mobil i ty tests) Mob i li zation, join t , vs. j o i n t manipulation, 488 Monounsaturated fatty acids, 733 M ot ivation, in active care, 3 1 8 , 3 2 1 -3 2 2 , 3 2 2 t Motor control cervical spine, 592-595 c l i n i cal assessment low back pain, 597-602 l umbar m u l t i fidus, 600-60 1 , 6 0 1 superfici a l muscles, 602 transversus abdomi ni s , 598-599, 598-600, 600t motor re-education (See M otor re-education) spinal biomechanics of, 586-5 88, 586-588 c hanges w i t h pai n , 590-59 1 , 5 9 1 l umbar multifidus, 588, 588, 589 mechanisms of, 5 88-592, 589-59 1 transversus abdo m i n i s , 587, 587 spinal pain and, 586, 6 1 3-6 1 4 Motor control tests, 248-2 5 2 , 2 4 8 t , 762, 762t abdomi nal hollowi ng, 249-250, 250 cervico-cranial flexion test of J u l l , 2 5 0-2 5 2 , 25 1 one-leg standing test, 248-249, 249, 249t M otor learni ng, 5 1 4-5 1 5 , 585-606 segmen tation approach , 595 si mplification approach , 595 stages of, 596, 6 1 7-6 1 8 , 6 1 7 t M otor re-educati o n , 585-606 activation phase of, 602-604 effectiveness of, 597 functional p hase, 606 for low back pain , 596-597 segmentation approach, 595 s i m p lification approach, 595 s k i l l precision p h ase of, 604, 604-605 superficial and deep m uscle coactivation phase of, 606-607 Mouth, tac t i l e perception o f, 405 M o u t h ope n i ng tes t , 76 7 Movement patterns, eva l uation of, 2 1 2-2 1 7, 2 1 4-2 1 7 MRI i n diagnostic triage, 1 3 8 , J 38, 1 3 8t in pre-employme n t testing, 277 M ultidisciplinary approach, i n active care, 3 2 1

960

-

Index

M u l t i fi d i anatomy of, 588 post-iso metri c relaxation for, 436, 436 spinal motor control and, 588, 5 8 8-589 M uscle c haracteristics, in low back pai n , 1 2 M uscle energy procedures « M EP ) , concepts, 408, 410 M uscle fatigueabi l i ty, i n low back pain , 1 1 - 1 2 M uscle relaxants, 92 1 -922 M uscle spra i n , spinal pai n related to, 1 1 7 M uscle strengt h , i n low back pai n , 5 7 M uscle tone etiology and terminology, 2 04 resting, assessment of, 204 tactile perception and, 403 types o f hyperto n i c i ty, 205t M u scle weakness in cervical radicu lopath i es, 1 32-1 3 3 , 1 32 t i n l u m bar radicu lopathies, 1 32 , 1 32 t tigh tness weakness, 2 04 Muscles (See also spec i fi c muscle) central nervous system i n function of, 5 3 2-533 classi fication of by dysfunc tio nal tendency, 3 8 , 3 8 t fu nctional , 3 7 tigh tness, 4 11 -4 1 2 , 4 ] I t deep vs. superfici a l , 3 8 , 3 8 t hypertonus, 783 hypotonus, 783 i n h i b i ted, assessment of, 2 1 2-2 1 7 , 2 1 4-2 1 7 l i kely to be i n h i b i ted, 2 0 5 , 206t l i kely to be tight, 2 0 5 , 2 0 6 t phasic development of, 545-548 fu nctional insufficiency of, 549-550 listing of, 539t nature o f, 533 postural function of, 543-545 postural , 682 responsible for resp i ration, 37 1 role i n stab i l i ty, 1 03 , 1 03 t shorten i ng of, 324-3 3 5 , 3 3 5 t tigh tness assessment of, 207-2 1 2 , 207-2 1 4 Janda defini tion, 4 1 1 --4 1 2 tonic, 3 7 , 38, 2 04-2 0 5 , 783 developmen t of, 545-548 l is t i ng of, 539t nature of, 533 Muscular i mbalance agon ist-antagonist m uscles coac tivation and, 3 5-36 assessment of, 203-2 2 5 gai t , 2 0 7 , 220, 2 20-2 2 1 hypermobili ty, 2 2 2 , 222-224 i n h ibited muscles, 2 1 2-2 1 7 , 2 1 4--2 1 7

standing posture, 207, 2 1 6-220, 2 1 8-2 1 9 tight muscles, 205-2 1 0, 205-2 1 2 concepts, 533 defined, 2 04 layer ( Strati fication) syndrome, 206, 207 lower crossed syndrome, 2 0 5 , 206 m uscle l i kely to be i n h i b i ted, 205, 206t m uscle l i kely to be tight, 205, 206t nature of, 5 33-534 in neck conditions, 8 5 8-859, 859t neurodevelopmental factors i n , 37--40, 39t, 2 04-205 posture and, 37-40, 38 spinal stab i l i zation and, 5 5 1 -552 upper crossed syndrome, 205, 206 Myelopathy, neck conditions related to, 854 Myofascial pain , spinal pai n related to, 1 1 7 Myofascial trigger poin ts (See Trigger po i n ts ) Nac h l as test, 2 3 2 , 232 Narcotic analgesics, 920 Neck fascia, soft tissue manipulation of, 394-395 , 3 95 m ac h i ne exercise, 6 7 7 Neck Bournemouth Questionnaire, 1 62 , 1 8 ] Neck condi t ions, 853-854 active care for, 2 0-2 1 , 2 1 t acute pain, 8 5 5-856 b iopsychosocial approach to, 854-855 case study cervical discogenic radiculopathy, 880, 880-88 1 neck pain and headache, 874, 8 74-8 77 temporomandibular joint syndrome, 878, 8 78-8 79 c hroni c pain, 856 c h ronicity of, 60 classification of, 854-8 5 5 , 856t c l i nical course, 56 diagnostic triage, 8 5 3-854 di fferential diagnosis, 8 53-854, 8 5 5 t etiology fracture/dislocation, 853 i nfection, 854 i nt rasp i nal/intracran ial considerations, 853-854 malignancy, 854 myelopathy, 854 radiculopathy, 854 functional screen , 8 5 8-873 i m pairments associated w i t h , 8 5 7-8 58 non-organ i c pain signs for, 1 94- 1 95 outcome assessme n t for, 1 56, 1 62 , 1 73- 1 74, 1 82 reactivation tec h n i ques, 8 5 8 red flags, 8 5 3 , 8 5 3 t r i s k factors for, 58-59 ri sk factors for chro n i c i ty, 1 87 , 1 8 8t structural pathology, 856

Index

upper crossed syndrome, 858-860, 859t Neck Disab i l i ty I ndex (NDI), 1 56, 1 73 - 1 74 Nerve root com press ion due lo herniation, case study, 837-839, 83 7-83 9 due lo spinal stenosis, case study, 844, 844-845 Nerve root pa in cervical , 1 32- 1 3 3 , 1 3 2t lumbar, 1 32 , 1 32 l , 1 3 3 t si mple backac he vs., 1 3 1 - 1 3 3 Neural arch, damage lO, 98 Neurodevelopmenl i n i n fants, 3 8-39, 39l muscu lar i m balance and, 3 7-40, 39t, 204-205 Neurodynamics (See also Adverse neurodynamic lension ) defi ned, 465 Neurologic loss, progressive, spinal pai n related to, 1 30- 1 3 1 Neuromobi l i zalion tec h n i ques, 464-485 anterior and middle scalene, 482-4 8 3 , 482-483 an lerior h i p capsu lar mob i l i zation, 472, 4 74 anlerior-to posterior rib mob i l i zation, 478-479, 4 79 femoral nerve strelch tesl (FNST), 472, 4 73-475, 474l latissimus dorsi, 48 1 , 48 1 levalor scapu la/posterior scalene, 479-480, 480 pecloralis m i nor, 48 1 , 48 1 piriform i s slretc h , 470, 4 7 1 posterior h i p capsular mobi l i zation, 470, 4 70 poslerior shoulder capsule, 479, 4 79 poslerior-lo-an lerior ri b mob i l i zation, 478, 4 79 precau l ions for, 466 re-evalualion, 483-484 reclus femoris standing sel f-slre lch, 472, 4 74 slider lechn ique, 483-484, 484-485 slump slider, 47 1 , 4 72 slump lensor, 47 1 , 4 72 slump lesl , 466, 467-468, 468 slernocleidomastoid, 482, 482 s lraighl leg raise, 468, 468-469, 470-47 1 superior-lo-i nferior rib mobil i zation, 480, 480-48 1 lensor tec hn ique, 483-484 leres major, 479, 4 79 upper l i m b neurodynamic lests, 472, 474-477, 4 76-4 77 upper lrapezius, 482, 482 Neuropathic drugs, 922 Neuropathic pa i n cen tral sens i t i zation and, 40-46 cOrl icopetal nocicept ive transmission i n , 40, 43 defined, 40 pathophysiology of, 44-45, 44-46, 45, 4 5 t Neurophysiological factors in act ive care, 7, 32 1

--

961

i n m uscular i m balance, 3 7-40, 39t in pai n , 35-46 Neu tral posture, defined, 1 02 Neutral zone, i n spine stabil i ty system, 3 2 , 32 NIOS H Low Back Atlas, 229 Nociception, 729 Nociceptive cha i n , 7 8 3-784, 784t Nociceptive somatomotor effect , 3 5 5 Non-organic p a i n signs for neck conditions, 1 94- 1 95 Waddell's for low back pai n , 1 89- 1 95 , 1 92- 1 94 NSA I Ds, 920-92 1 Nutri tional considerations, 728-73 7 i n fl ammation and [Tee radicals, 7 3 2-733 i nflammation and i nsulin resistance, 7 3 1 -7 3 2 i n flammation and omega-6 fatty acids, 7 3 3-734, 734t i nflammation and pain , 729-7 3 1 , 730l overview, 729 potassi u m and magnes i u m , 735-736, 736t Obl iques, stabil i zation exercises, 1 05 Occipi tal-atl antal joint, manipu l ation of, 4 95, 495-496 Occupational Health Guidelines (OH G ) , 8 5 , 86t O G E effect , 355 Omega-6 fatty acids in foods, 734t i nflammation and, 7 3 3-734 One-leg standing test, 764 balance/motor control test, 248-249 , 24 9, 249t in gait assessmen t , 220, 2 2 1 Opioid analgesics, 920 Orebro Musculoskeletal Pain Screen i ng Question nai re, 743-744 Orofacial region coordi n ation test, 872-873 , 8 72-873 upper crossed syndrome and, 860 Osteoart h ri tis hip, 90 1 -902 knee, 900-90 1 Osteomyel i t i s , spinal pain related to, 1 2 8 , 1 29l Osteopat h i c myofascial release method , vs. man ual res istance tec h n iques, 4 1 3 Osteoporosi s , 1 3 5 , 900 Oswestry Disab i l i ty Index (OD I ), revised, 1 70- 1 7 1 , 261 compared t o Roland-M orris D i sabi l i ly Question naire, 1 54 , 1 5 5 t development of, 1 5 3 usefulness of, 1 5 3 , 1 54t Outcome assessment, 1 46- 1 63 objective, 1 47 , 1 49 subjective, 1 47 Outcome assessment tools c ri teria for, 1 47- 1 49

962

--

Index

Ou tcome assessment tools, criteria for (contd. ) cei l i ng effects, 1 49 floor e ffects, 1 49 practicality, ] 49 reliabili ty, 1 48 responsiveness, 1 48- 1 49 val idity, 1 48 for fu nctional di sabil ity, 1 50t, 1 53- 1 59 for general health, 1 50 t , 1 52- 1 5 3 , 1 5 2 t for low back pai n , 1 50t, 1 5 3- 1 5 6, 1 5 5 t for lower extre m i ty, 1 5 8- 1 59 for neck condi tions, 1 56 , 1 62 for pai n , 1 50- 1 52, 1 50t for patient satisfaction, 1 50 t , 1 60- 1 6 1 , 1 60 t Pa tient-Speci fic Functional Scale (PSFS), 1 50t, 1 59 , 1 79 for psychological distress, 1 6 1 - 1 62 for upper extre mi ty, 1 56- 1 5 7 use o f, 1 47 u t i l i ty of, 1 62 for work s tatus, 1 50 t , ] 59- 1 60 Outcomes, SMA RT, 754, 754t Overreaction, in Waddell non-organic low back pain signs, 1 9 1 , 1 93- ] 94, 1 94 P val ue, 1 48 Pain abnormal i l l ness behavior, 79-80, 80t biomedical model of, 73 biopsychosocial model of, 7 3-74, 75 Cartesian model o f, 73, 73 decondi tioning and, 4 decondi tioni ng syndrome and, 1 3- 1 5 defined, 73 fear-avoidance bel iefs and, 2 96-297 i n fl a m mation and, 729-7 3 1 , 730t loca tion of, physical performance test battery, 267 low back (See Low back pain) management of chronic, 929 management vs. avoidance, 1 4- 1 5 , 296 motor con t rol and spinal, 586 neuropathic (See Neuropathic pai n) neurophysiological factors in, 3 5-46 phantom l i m b, 40 psychogenic, 42 referred (See Referred pai n) rela tionship to tension , 489 respiration dysfunction and, 3 7 3-3 75 role in i m pairment and disab i l i ty, 9- ] 0, 1 1 sacro i l i ac joint, case study, 846, 846-848 tissue hea l i ng and, 7 Pain adaptation t heory, 3 6 Pa in affec t , 1 5 1 Pai n assessmen t , 1 50 affec t, 1 5 ] di agrams, 1 5 1, 1 5 1 - ] 52 severi ty/i ntensi ty, 1 50- 1 5 1 , 1 5 1

Pai n assessment tools, 1 50- 1 52 , ] SOt Pain diagrams, 1 5 1 Pai n d i agrams, 1 5 1 - ] 52 Pain pathway, 74 ascending, 75 desce n d i ng, 75 Pai n points, 489, 489t Pai n reli e f i n active care, 3 1 4-3 1 5 i n b iopsychosocial model, 85 Pai n-spasm-pain model , 36 Pai n Stages of Change Questionnaire (PSOCQ), 3 1 8 Pars i nterarticularis, stress fractures [" om , 1 3 5 Passive moda l i ties, for acute low back pain, 1 9 Patellofemoral pai n syndrome, 1 5 8 Pathodynam ics, defined, 465 Pathology functional, 777 functional v s . structural, 777 i diopathic, 777 nonspecific, 777 Patien t , relationship with doctor (See Doctor/patient relationship) Patien t-centered approac h , in active care, 1 7, 1 7- 1 8, 1 8, 322 Patient-cen tered counsel i ng, i n active care, 3 1 8 Patient-centered outcomes, 1 47 assessment of (See Outcome assessment) Patient Profile, 7 5 5 , 758 Patient satisfaction, ou tcome assessment, 1 50t, 1 60- 1 6 1 , 1 60t, 1 80 Patient Satisfact i o n Subscales (PSS), 1 6 1 , 1 6 1 t , 1 80 Patient sel f-reports, 2 6 1 -262 (See also Ou tcome assessment) Patient-Speci fic Functional Scale (PSFS), 1 50t, 1 59, 1 79 Patient-Speci fic Questionnaire (PSQ), 2 6 1 Patrick test, 1 4 1 Pearson's correlation coeffic ient, 1 47 Pectoralis major post-isometric relaxation for, 443-445, 445 tight ness, evaluation o f, 205, 20M, 207 Pectoralis m i nor neuromobil i zation techn ique, 48 1 , 4 8 1 post-isometric relaxation for, 445-446, 446 Pelvic floor exercises, yoga-based tra i n i ng effect of, 582 for Levator A n i , 5 8 2 for perineal muscles, 583 for u rogeni tal system , 5 82-583 Pelvic floor m uscles functions of, 582 yoga-based exercises for, 5 82-5 83 Pelvic obliquity, 79 1 -796, 792-796 Performance Assessment and Capacity Tes t i ng Spinal Function Sort (SFS), 1 54- 1 5 5

Index

Perineal m uscles, yoga-based exercises for, 5 8 3 Periosteal poin ts, soft tissue m a n i pu lation of, 397-398, 3 98 Personal i ly, aspects of, 890, 890 Pes anseri nus of the tibia, 398 Phantom limb pain, 40 Phasic muscle system, 3 7, 38, 205 Phasic muscles developmenl of, 545-548 hmc l ional insufficiency of, 549-5 50 listing or, 539l nature or, 5 3 3 postural function of, 543-545 Physical Component Su m mary, in SF-36, 1 5 3 Physical performance abi l i ty test, 226-2 54, 2 60-2 72 aerobic fi lness tests, 2 5 2-2 53, 2 5 2 t balance/motor control tests, 248-2 5 2, 248t abdom inal hollowi ng, 249-250, 250 cervico-cranial flexion test of J u l l, 250-252, 2 5 1 one-leg slanding test, 248-249, 249, 249t flexi bil i ly/mobi l i ty tests, 230-240, 2 3 1 t ankle, 2 3 1 -232, 23 1-232 cervical spi ne, 2 3 8-239, 238-23 9 h i p, 232-234, 233-235 knee, 232, 232 lum bar spi ne, 234-2 36, 236-23 7, 2 3 8 shoulder, 239-240 i mplementalion of, 2 5 3-254 indications for, 229-230 physical performance test battery, 2 62-272 pu rpose or, 227-229 strengt h/endurance tests, 240-248, 240t grip strength, 24 7, 247-248 side bridge, 244, 245 squa�, 240-242, 24 1 trunk extensor test, 244-245, 246, 246t trunk flexor tesls, 242, 242-244, 243 t-244t usef-u l ness of, 228, 228t Physical perrormance test battery, 2 62-272 biomechanical analysis of, 2 67-268, 269-270 components of, 2 62, 2 6 3 l, 264-265 360-degree rollover, 2 6 3 t, 265 50-foot walk, 263l 5-mi nute walk, 263t loaded reach, 263t, 264, 27 1 -272, 2 73 sit- lo-stand, 263t, 264, 269, 27 t , 2 73 Sorensen ratigue test, 2 6 3 t, 265, 266 trunk flexion, 2 6 3 t, 264 eleclromyographic analysis of, 2 6 8-269, 2 71-2 72 factors lhat i n fl uence gender, 2 66-267 pain localion, 267 gai t analysis i n, 2 6 8-269, 269-2 72 movement patterns in, 267-2 68 reliab i l i ty of, 2 62-263

-

963

responsiveness of, 263 vali d i ty of, 2 63-2 66 P hysician (See also Doctor/patienl relations h i p) role i n return to work screeni ng, 2 8 5-289, 2 8 6 l Piriform is m uscle post-isometric relaxation for, 42 6-428, 42 7-429 tightness, evaluation of, 2 1 0, 2 1 2 P i ri formis stretch, 76 9 neuromobil i zation lec h n i que, 470, 4 7 1 Plantar flexors agis t ic-eccen tric contraction approach ror, 3 60-36 1 , 3 6 1 Thera-Band exercise for, 364 Plyometrics, 708-7 1 1 leg raise throw, 7 1 0, 7 1 0-7 1 1 with medicine bal l, 709-7 1 0, 7 1 0 overview, 708-709 w i t h punch i ng bag, 709, 709 Polyunsaturated fatty acids, 7 3 3 Position sense, i n l o w back pain, 1 2 Posi tional release, vs. manual resistance techniques, 4 1 3 Post-contrac tion i n h i b i t ion, 408, 4 1 0 Post-faci l i tation s tretch (PFS) concepts, 4 1 1 , 4 1 3 for muscle relaxation and s tretch erector spinae, 432-43 3 , 432-434 gluteus maximus, 429 hamstri ng, 4 1 9-42 1 h i p adductors, 422-423 iliopsoas, 424-425 l u m bar m u l t i fidi, 434 piriform i s, 42 7-42 9 posterior cervical m uscles, 434-436 quadratus l u mborum, 430-43 1 quadriceps, 429 rectus femoris, 429 tensor fasci a l atae, 426-42 7 technique for, 4 1 7-4 1 8 Post-isometric rel axation (PIR) concepts, 4 1 0, 494 joi n t mobi l i zation procedures, 45 1 -453, 45 1-455 h ip, 45 1 , 45 1 l um bar spine, 45 1 -4 5 2, 45 1-453 rib, 453, 455 t horacic spine, 452-453, 453-455 for m uscle rel axation and s tretch, 4 1 8-450 erector spinae, 430, 432-43 3, 432[435 gastrocnemius, 448-449, 449 glu leus max i mus, 429, 429 hamstri ng, 4 1 9-420, 4 1 9-42 1 h i p adductors, 420-422, 422-423 i liopsoas, 422-425, 424-425 i n fraspi natus, 447, 447-448 levator scapulae, 43 7-439, 438-43 9 l u m bar m u l t i fid i, 43 3-434, 434

964

--

Index

Post-isometric relaxation (PIR), for m uscle relaxation and stretch (contd.) pectoralis major, 443-445, 445 pectoralis m i nor, 44 5-446 , 446 p i ri form is, 426-428, 427-42 9 posterior cervical m uscles, 434-436, 434-436 quadratus lumborum , 429-430, 430-43 / quadriceps, 42 8-429, 429 rectus femoris, 4 2 8-429 , 429 scalenes, 44 1 -442 , 443-444 soleus, 449-450, 450 sternocleidomastoid, 440-44 1 , 44 1-442 suboccipitals, 439-440 subscapularis, 448, 448 supraspinatus, 446-447 tensor fascia latae, 425-426, 426-427 upper tra pezius, 436-43 7, 43 7-438 sel f, 4 1 8 technique for, 4 1 0, 4 ] 5-4 1 7 Posterior, scal ene muscles, neuromob i l i zation tech niques, 480 Postural correction , in sensory motor stimulation, 520, 520-52 1 Postural developme n t 4 . 5 mont hs, 540-54 2 , 54 1 fourth t h rough sixth week, 538, 5 3 8-539 neonatal, 536, 5 3 6-538 3.5 months, 5 3 9-540, 540 Postural m uscles, 5 3 3, 682 Postural on togenesis diaphragm i n , 55 1 motor programs and, 5 34-5 3 5 Postural stab i l i ty flexible, 567 rigid , 567 Postural syndrome, 3 3 1 -3 3 3, 802 c l i n ical i n tervent ion, 332, 3 32-3 3 3 , 333 pathoanatomi cal explanation, 3 3 2 phenomenological pattern , 3 3 1 -3 3 2 Posture cog wheel model of joi n t centration, 3 7-38, 38, 30 1 , 302, 3 5 3 , 353, 78 1 , 782 ror core trai n i ng, 7 1 4-7 1 5 correction of (See BrLigger methods) muscular i m balance and, 3 7-40, 38 neu t ral, defined, 3 2 patterns of poor, 39-40, 42, 43 si t t i n g in a car, 3 ] 1 , 3 1 3 ergonomic workstation advice about, 302, 303-304 prolonged, 300-30 1 ris ing h-om chair, 304, 306 slumped, 3 7-3 8 , 38, 30 1 -302 slumped s i t t i n g, 3 7-38, 38 standi ng

assessment for muscular i m balance, 2 1 6-220, 2 1 8-2 1 9 assessment o f, 207 for weigh t-trai n i ng, 693-694 yoga-based trai n i n g and, 567 Potassi u m food source of, 736t i n fl am mation and, 735 Power c lean, i n free-weight trai n i ng, 707, 707 Practica l i ty, of ou tcome assessment tool, 1 49 Pract ice guidelines, 933-944 auditi ng, 942, 942 characteristics of good, 9 3 8 eva l uation of, 9 3 8 evidence-based, 935-936 fu ture of, 943 h istory of, 934 i mplementation of, 939-94 1 for m uscu loskeletal rehabili tation, 939, 94 I research and, 93 5-936, 936 s teps in development, 937-93 8 Prac t i t ioner audit, i n biopsychosocial model, 86, 86-8 7 Prayer, power o f, 896-897 Pre-employment test i ng American with D isabil i t ies Act and, 280-2 8 1 Equal Employment Opportuni t ies (EEO) laws and, 2 7 8-279 validity of, 2 77-2 78 Pre-exh aust train i ng, i n weigh t-tra i n ing, 691 Pre-placement screening, 2 83-2 85 val i d i ty of, 2 77-2 78 Predictive val id i ty, 1 48 Prevention active care role i n, 1 8 biomechanics oC 34, 34-35, 35 in doctor/patient relationship, 893-894 patien t advice, 35 Primary movements, Brugger defi ni tion, 355 Progressive neurologic loss, spi nal pain related to, 1 30- 1 3 1 Propriocept i on, 663 Proprioceptive neuromuscular fac i l i tation (PNF), 409 concepts, 408 v s . sensory motor sti mulation (SMS), 5 1 4 Proprioceptive taping, 663-665 ki nesiotapi ng techniques, 664 for pelvic crossed syndrome, 665, 665 types of tape, 663-664 for u p per crossed syndrome, 665, 665-666 Pro tocol, defined, 936 Proximal gai t, 2 2 0 Psoas-rectus femoris, flex i b i l i ty/mob i l i ty test for, 233, 2 3 3-234 Psoas stretch, 76 9

Index

Psychogenic pai n , 42 Psychological factors, 1 85- 1 8 7, 743-744 Psychology, of functional stabil ity trai n i ng, 6 1 5-6 1 6 Psychosocial ractors (See also Yellow flags) assessment of, 1 88- 1 95 in low back pai n , 57, 1 85- 1 87 outcome assessment for, 1 6 1 - 1 62 in treatment of low back pain , 2 86-2 87 Pull-down, mac h i n e exercise, 6 76, 697-698 , 6 98 Pulley crunch machine exercise, 702, 703 exercises using, 654, 655-659 row mac h i ne exercise, 700, 700-70 1 spinal rotation mac h i ne exercise, 70 1 , 701 Punch i ng bag, plyometrics using, 709, 709 Push-ups exercise, 639, 639-640, 770 functional tes t , 76 7, 866, 866-86 7 movement pattern test, 2 1 5, 2 1 5-2 1 6 Pus h i ng, a wheeled cart, 309 Quadratus lumborum as a lumbar stabi l i zer, 1 02 post-isometric relaxation for, 429-430, 430-43 1 stabi lization exercises, 1 03 , 1 04, 1 05 tightness, evaluation of, 2 1 1 , 2 1 3 Quadriceps post-isometric rel axation for, 42 8-429, 429 t igh tness, eval uation of, 2 3 2 , 232 Quality assurance, 5 1 -66 (See also Evidenced-based healt hcare) Quebec WAD Guidelines, 2 0-2 1 , 2 I t, 8 54-85 5 , 856t Radial nerve bias, upper l i m b neUl-odynamic test, 476, 476t, 4 7 7, 478 Radiculopat hy cervical , 1 32-1 3 3 , 1 3 2 t cervical discogenic, case study, 880, 880-88 1 lumbar, 1 32 , 1 32 t , 1 3 3 t neck condit ions related t o , 854 Radiography in diagnostic triage, 1 3 7 , 1 3 7 t o f lumbar spine (stand ing), 795 in pre-em ployment testi ng, 2 7 7 Randomi zed controlled trials, l i m i tations of, 936-93 7 , 937t Range of motion (ROM) assess ment of (See Flexi bili ty/mobi l i ty tests) measurement of, 230 spinal, in low back pai n, 1 1 Ratio promotion, i n i sotonic traini ng, 6 7 1 Reach , loaded, i n p hysical performance test bat tery, 263t, 264, 2 7 1 -2 7 2 , 2 73 Reach exerc ises, 65 1 , 65 1-652 Reac tion time, in low back pai n , 1 2

--

965

Reactivation advice, 4, 296, 297-3 1 7 , 2 9 7 t (See also Active care) i n biopsychosoci a l model , 84-85 causation i n , 299 daily activi ties, 303-304, 306-3 1 3, 307, 3 1 1 ergonomic workstation advice, 302-303, 302- 303 goal setting i n , 297-298 l i fting, 3 1 1 , 3 1 3-3 1 4 , 3 1 4, 3 1 4t for neck conditions, 8 5 8 p a i n lIS. i njury, 298 rest lIS. activity, 300 sleep, 303, 305 specific advice, 299-300 Reasonable accommodation, American with Disabi l i t ies Act defini tion, 2 8 1 -2 8 2 Receptor field, 43 Reciprocal i n h ib i tion (RI), 408-4 1 0 Recon d i tioning, i n biopsychosocial model, 86 Rectus abdomi n i s , stabil i zation exercises, 1 05 Rect us femoris post-isometric rel axation for, 42 8-429, 429 standing sel f-stretch, 4 7 2 , 4 74 tightness, eva l uation of, 2 0 8 , 209 Red flags diagnostic i m aging and, 76 i n d i agnostic triage, 8 2 , 82t, 83, 1 26- 1 2 7 , 2 2 7 l ow back pai n and, 799, 799t neck condi tions and, 853, 8 5 3 t Referral, i n b iopsychosoci a l model , 8 6 Referred pai n early d iscussion of, 42 non-dermatomal , 44 Reflex creeping, 542-543, 545-54 7 Reflex locomotion, development o f, 542-543 , 543-544 Reflex spasm, 4 1 2 Reflex turning, 542-543 , 544-545 Reflexes affected by cervical radieulopathies, 1 3 2- 1 3 3 , 1 32 t affected b y l umbar rad iculopath ies, 1 32 , 1 32t i nfant automatic gai t , 5 3 7 , 53 7 calcaneal (heel) reflex, 5 3 7-5 3 8 , 538 Col l i s horizon ta l reaction, 5 3 2 , 532 crossed extension reflex, 5 3 7 , 53 7 support reaction , 5 3 7 , 53 7 suprapubic reflex, 5 3 6 , 536 Regional disturbances, in Waddell non-organic low back pain signs, 1 9 1 , 1 93 , 1 94 Rehabili tation, postsurgery, 928-929 Reiter di sease, spinal pain related to, 1 3 1 Release phenomenon, 494 Reliabil i ty of outcome assessment tool, 1 48 of physical performance test bat tery, 262-263

966

--

Index

Religion , i n hea l i ng, 895-896 Repet i t ive strai n i nj uries, 1 4 , 34, 34-3 5 , 35, 759, 759t Report o f findi ngs, in active care, 3 1 6-3 1 7 Reposi tion i ng abi l i ty, i n l ow back pain , 1 2 Researc h , practice guidelines and, 935-93 6 , 936 Resistance tra i n i ng (See also Weight-tra i n ing) concepts o r, 690-692 Respiration (See also Brea t h i ng) assessment o r, 862, 862-863 in fu nct ional activi ties, 3 7 9 overview, 370, 3 7 6-3 7 8 , 3 7 7 t prone, 3 7 9 resp i ratory fau l ts, 3 7 7 t seated, 3 7 8 , 3 78 su pine, 3 7 8-3 79, 3 79 i n nuences o n , 3 70 metabolic [u nction of, 375 m uscles responsi ble for, 3 7 1 normal, 3 70-3 73 , 3 72, 3 73 spinal stabi l i ty and, 3 7 3-374, 5 52-5 53 Respiratol-y dys [-u nction i n fluence on general heal t h , 3 75-3 76 treatment of, 560, 560-56 1 (See also Respi ratory tra i n i ng) types of, 3 73-3 7 5 Res pi ratory exercises, yoga-based tra i n i ng effect of, 5 68-5 69 [or lower abdom i nal breath control, 569-5 7 1 , 5 70-5 7 1 [or m i ddle breat h con trol, 5 7 1 -5 73 , 5 72-5 73 ror normal molion, 569, 5 70 ror upper breath control, 5 73-5 74, 5 73-5 74 ror whole-breath con tro l . 5 7 6 , 5 76 Respiratory syn kinesis, 4 1 7 Respi ratory tra i n i ng, 3 80-3 86 autom a t i zation, 3 8 3 beach posture, 3 8 3 , 384 benefi ts of, 380, 380t Bu teyko Con trol Pause, 3 84-3 8 5 exercise prescri ption, 3 8 5-3 8 6 exerc ises [or, 382, 3 82-3 8 3 , 383 facil i tation tec h n i ques, 384, 385 ki nesthetic awareness, 3 8 1 -3 8 2 motor trai ning of, 380-3 8 1 strategies [or, 380 trou bleshooti ng, 3 8 6 Responsive ness, o f outcome assessment tool. 1 48- 1 49 Retrocapital support of t h e foot, i n B rLigger method, 365-366 , 366 Return to work i n g screening, [-unctional capaci ty evaluation, 289-290 Reverse fly exercise, 6 78 Review cri teria, defined, 9 3 6 R h i zotomy, 924

Rhyth m i c stabi l i zation, 4 1 0 Rib mob i l i zation anterior-to posterior, 4 7 8-479, 4 79 posterior-to-anterior, 478, 4 79 superior-to-i n ferior, 480, 480-48 1 Ribs post-isometric relaxation [or, 4 5 3 , 455 in respiration, 5 5 2-553 u pper, mani pulation 0[, 498-500, 500-501 Roland-Morris D i sabi l i ty Question nai re (RDQ), 1 72 , 26 1 compared to Oswestry Disability Index, 1 54, 1 5 5t description, 1 54 Rotary torso mac h i ne exercise, 70 1 -702, 702 Rotatores, post-isometric relaxation [or, 436, 436 Row barbell, 704, 704 w i t h dumbbe l l , 704, 704-705 machi ne exerc ise, 6 96, 699-700 Sacro-i liac tests, 800, 800t, 80 1 , 802 Sacro i l i ac joi nt d i agnostic block of, 1 1 5 discography of, 1 4 1 m a n i pulation of, 502, 503 pai n , case study, 846, 846-848 spinal pain related to, 1 1 7- 1 1 8 , 1 40- 1 4 1 Sacroiliac joi n t blocks, 924 SAID p ri n c i ple, 6 1 4-6 1 5 Satisfaction, patient, assessment o[ job satisfaction, 1 6 1 outcome, 1 50t, 1 60- 1 6 1 , 1 60t, 1 80 Pati e n t Satisfaction Subscales (PSS), 1 6 1 , 1 6 1 t , 1 80 symptoms, 1 60- 1 6 1 Saturated fat ty acids, 7 3 3 Scalene muscles in breathi ng, 3 7 1 neuromobil i zation techn iques anterior and m iddle, 482-48 3 , 482-483 l evator scapula/posterior, 479-480, 480 post-isometric relaxation [or, 44 1 -442 , 443-444 Scalp, fascia, soft tissue manipu lation 0[, 396 Scapula m anual resistance techniques for, 4 5 3 , 455, 456 tightness, evaluation 0[, 2 1 6 , 2 1 7 [, 207 Scapulo-thoracic fac i l i tation, 453, 455, 456 Scar(s) c l i n ical picture of, 399-400 exteroceptive t herapy for sensi t ivity, 404-405 pathomechanism of, 399 soft t issue m a n i pu l ation 0[, 398, 400-402 Schedule for N onadaptive and Adaptive Personali ty (SNAP), 1 86 Scheuerm a n n kyphosis, 1 3 6 Sciatica, 56

Index

case study, 846, 846-848 surgery for, 78 Scoliosis, 1 3 6 Scoliotic antalgia, lumbar, description of, 3 34, 335, 337 Segmentation approach, for motor relearning, 595 Sel f-care prescriptions, in evidenced-based practice, 754 Self-efficacy, in active care, 3 1 8 Self post-isometric relaxation (PIR), 4 1 8 Self-reports, 2 6 1 -262 (See also Outcome assessment) Self-stretch, 4 1 8 erector spi nae, 433, 434 gastrocnemius, 449, 449 hamstring, 420, 42 1 il iopsoas, 424-425, 425 levator scapulae, 439, 439 l u m bar spi ne, 452, 452-453 pectoralis major, 444-445, 445 piriformis, 428, 428-42 9 quadratus lumborum, 430, 43 1 scalenes, 442, 444 soleus, 450, 450 sternocleidomastoid, 44 1 , 442 tensor fascia latae, 426, 42 7 t horacic spi ne, 452, 453-455 upper trapezius, 437, 438 Self therapy, exteroceptive t herapy, 406 Sem i-traction posi tion, for low back pain, 300, 3 0 1 Semispinalis, post-isometric relaxation for, 434-435, 435 Sensitization central fibromyalgia and, 44 neuropathic pain and, 40-46 defined, 44 pathophysiology of, 44-45, 45, 45t Sensory motor stimulation ( SMS), 5 1 3-529, 524, 525 corrected stance on one leg, 520, 52 1 -522, 522 devices and aids, 5 1 5-5 1 6, 5 1 5-5 1 6 balance shoes, 5 1 5 , 5 1 6, 524-526, 525-526 exercise ball, 5 1 6, 526-5 27 Fitter, 5 1 5, 5 1 6, 526 mini trampoli ne, 5 1 6 , 5 1 7, 527, 52 7-528 rocker board, 5 1 5 , 5 1 5, 52 3-524, 525 twister, 5 1 5, 526 wobble board, 5 1 5, 5 1 5, 5 23-524, 525 goals of, 528 indications for, 5 1 6 , 5 1 7t, 529 j umps, 524, 525 lunges, 522, 523-524 motor learning i n, 5 1 4-5 1 5 overview, 5 1 6-5 1 7, 5 1 7t postural correction, 520, 520-52 1 , 5 2 8

-

967

sequence for, 525-52 6 small (short) foot, 5 1 7-5 1 9, 5 1 8 therapeut i c approaches, 5 1 4 vs. propriocept ive neuromuscular fac i l i tation, 5 1 4 Sensory-motor train ing, i n fun ct ional i n tegrated train i ng, 642-643 , 642-644, 770 Sensory-motor train i ng exercises, 642-644, 7 70 7 Rs decision points i n patient care, 772, 7 7 3 t SF- 1 2, 1 5 3 SF-36, 1 52 - 1 53, 1 5 2 t, 2 6 1 Mental Healt h Component, 1 5 3 Physical Componen t Summary, 1 5 3 Shear, i n tissue damage, 95 Sherrington's l aw of reciprocal i nnervat ion, 3 7, 2 04, 409 Shoes, tying, 307, 309 Shoulder acromioclavicular join t, manipulation of, 502, 504 flex i b i l ity/mobil i ty test for, 2 3 9-240 outcome assessment for, 1 56- 1 57 sternoclavicular j o i n t, manipulation of, 502, 504 S houlder abduction, movement pattern test, 2 1 6, 217 S houlder capsule, posterior, neuromobi l i zat ion tec h nique, 479, 4 79 Shoulder Evaluation Form ( S E F), 1 5 7 Shoulder P a i n and D isabi l i ty Index ( SPADI), 1 5 7 Shoulder rotators, Thera-Band exercise [or, 362 Side bridge endurance test, 244, 245, 766, 826-82 7 , 826-82 7 Side bridge exercise, 625, 625-626, 76 9 Side l i ft exercise, 6 75 Silverstolpe, 785 S i mplification approach, for motor relearni ng, 595 Simulation, in Waddel l non-organ i c low back pain signs, 1 9 1 - 1 92, 1 92, 1 93 S it-to-stand, i n physical performance test battery, 2 6 3 t , 264, 2 6 9 , 27 1 , 2 73 Si t-ups as strength/endurance test repe t i tive, 242, 242, 2 4 2 t static quarter, 2 4 3 , 243t technique controversies, 1 0 1 - 1 02 S i t t i ng i n a car, 3 1 1 , 3 1 3 ergonomic workstation advi ce abou t , 302, 303-304 prolonged, 300-30 1 rising from chair, 3 04 , 306 slumped, 3 7-3 8, 38, 30 1 -302 Skin , soft t issue manipulation of, 390, 3 90-39 1 Skin folding, 3 9 1 Skin roll ing, 3 9 1 S k i n sensi tivity exteroceptive t herapy for, 403-406 self t herapy for, 406

968

--

Index

Skin stretc h , 3 90, 390-3 9 1 Sl eepi ng, reactivation advice abou t , 303, 305 Slider technique, in neuromobilization, 48 3-484, 484-485 Slouch posture McKenzie correct i o n for, 3 3 2 , 333 s i t t i ng, 3 7-3 8 , 38, 30 1 -302 Slump s l i der neuromob i l i zation, 47 1 , 4 72 Slump tensor neuromob i l i zation, 47 1 , 4 72 S l u m p test, 466, 46 7-468, 468 Small (s hort) foot , i n sensory motor sti mulation, 5 1 7-5 1 9 act ive assisted model i n g of, 5 1 8-5 1 9 ac tive mode l i ng of, 5 1 9 , 5 1 9, 5 1 9t defined , 5 1 7 , 5 1 8 passive model i ng of, 5 1 8 , 5 1 8 S M ART outcomes, 754, 754t Smoking, low back pain and, 5 8 Social cogni tive theory, 3 1 7-3 1 8, 7 5 7 Sociodemographic factors, i n l o w back pai n , 58 Soft tissue defined , 3 8 9 s h i ft i n g of, 3 8 9 stre t c h i ng of, 3 8 9 Soft t issue mani pulation active scars, 398-402 barrier phenomenon, 389, 3 8 9-390 connect ive tissue, 3 9 1 , 3 9 1 fascias, 3 92-396 Ac h i l les tendon , 396, 3 9 7 back, 3 92-394, 3 93 b u t tocks, 3 94 , 3 94 extremi ties, 396 hee l , 396, 3 96, 3 9 7 neck, 3 94-39 5 , 3 95 scalp, 396 thorac ic, 394, 3 95 between metacarpals, 3 96-397 between metatarsals, 3 96-397 periosteal poi n ts , 3 97-3 9 8 , 398 s k i n , 3 90, 3 90-3 9 1 trigger points, 392 use of li ght pressure, 392 vs. manual resistance tec h n iques, 4 1 3 Soleus post-isometri c relaxation for, 449-450, 450 tight ness, eval uation of, 2 1 2 , 2 1 4, 2 1 7 , 2 1 8, 2 3 1 -2 3 2 , 232 Sorensen fat igue tes t , 2 6 3 t , 265, 266 Sorensen Test, 244-245, 246, 246t, 766, 828, 828-829 Spandex body su i t , use of, 894-895 Spasm , defined, 3 3 5 Speci fic i ty principle, for t ra i n i ng, 6 1 4-6 1 5 Sphinx exercise, 3 1 5, 6 3 7 , 63 7, 7 70 Spinal erectors, l i g h t ness, evaluation of, 2 1 1 , 2 1 3

Spinal exercises, yoga-based tra i n i ng effect of, 575-576 supine, 576-57 8 , 5 76-5 79 Spinal fracture, spi nal pai n related to, 1 29t, 1 30 Spinal fusion surgery, com pl ications of, 1 3 5- 1 36 Spi nal osteomyeli tis, spinal pain related to, 1 2 8, 1 29 t Spinal range of motion , i n low back pai n , I I Spinal stenosis decompression surgery, 927 as a diagnosis, 1 36 i n elderly, 904-906 diagnosis of, 904-905 surgical treatment of, 905-906 nerve root compression due to, case study, 844, 844-845 spinal pain rela ted to, 1 2 9t Spinal surgery cervical fusion, 927-92 8 on cervical spine, 926 l u m bar fusion, 927 on l u m bar spine, 925-926 m i crodiscectomy, 927 outcome risk factors, 926-927 overemphasis on, 7 8-79, 78t postoperative management, 92 5-929 activity restrictions, 92 7-928 conservative care, 925, 925t diagnostic triage, 1 3 5- 1 36 rehabi l i tation, 92 8-929 spinal fusion, 1 3 5- 1 3 6 spinal stenosis decompression , 927 Spin e-leg mechanism, 505 Spine-sparing, flmc tional scree n i ng exercises, 768, 76 9 Spine stability (See also Stabil i ty; Stabil i ty trai n i ng exerc ises; Stab i l i zat ion exercises) agonist-antagonist m uscle coactivation i n , 3 3-34 defined , 3 2 exa m ination of, 55 3-5 58, 553-559 functional screen i ng exercises, 76 9-771 locomotor development and, 550-5 5 1 motor control and, 5 86-58 8 , 586-588 muscles role i n , 6 1 3 m uscular i m balance and, 55 1 -552 neurophysiological [actors i n , 35-46 respiration and, 3 73-374, 552-5 53 treatment of instabi l i ty, 55 8-56 1 pathological respiration, 560, 560-56 1 patien t's vol un tary activi ty, 56 1 , 56 1-562 reflex stimulation, 560 Spine stab i lity system biomechanics of, 3 1 -3 5 agonist-antagonist muscles i n , 3 3-34 i njury prevention, 34, 34-3 5 , 35 i nstabil i ty, 3 1 -32

Index

neutt� zone i n , 3 2 , 32 whole body stab i l i ty and, 3 1 , 3 1 -32 Spi nous process axis pain , soft tissue manipu lation for, 398 low lu mbar pai n , soft tissue manipulation for, 398 Spiri lual factors, in hea l i ng, 895-896 Splenius capitis, post-isometric relaxation for, 436, 436 Split routine, in weight-tra i n i ng, 692 Spondyloarthropathy, spinal pai n related to, 1 3 1 Spondyloarthrosis, as a diagnosis, 1 3 6 Spondylol isthesis, spinal pai n related to, 1 1 7 Spondylolysis as diagnosis, 1 3 5 spinal pain related to, ] 1 7 Spondylosis as a diagnosis, 1 36 spinal pai n related to, 1 1 7 Spray and stretch, vs. manual resistance tech n iques, 4 1 3 Spri ngi ng of D 5 , 3 55-356, 357 Squats, 645, 646-648, 771 with free-weigh t , 70S, 705 gym bal l , isotonic tra i n ing, 6 75 one-leg, 765 si ngle-leg, 765, 8 1 4 , 8 1 4-8 1 5 a s strength/endurance test, 240-242, 24 1 repeti tive, 240-24 1 , 24 1 t static, 24 1 -242, 242t two-leg, 764, 8 1 2 , 812-8 1 3 Stabi l i ty (See also S p i n e stabi l i ty) form ula [or spinal, 99- 1 0 1 , 1 00, 1 0 1 instab i l i ty, 98-99 lumbar, 93- 1 09 muscles role i n , 1 03 , 1 03 l overview, 94 in sensol), motor stimulation, 528-529 lissue damage and, 94-97 Stabi l i ty trai n i ng exercises, 6 1 9-640, 620t back extensions, 635, 636 bird dog, 623, 623-624 braci ng, 622 bridge, 63 1 , 632 cat camel , 62 1 , 62 1 t curl-up, 630, 630 dead bug, 627, 62 7-62 9, 629 hamstri ng curls, 633, 634 push-up, 639, 639-640 side bridge, 625, 625-626 sphinx, 637, 637 wal l ange l , 638, 638 Stabil izat ion, i n isotonic tra i n i ng, 668-669 Stabil ization exercises advanced tec h n iques, 1 06- 1 09, 1 08 back extensors, 1 05- 1 06 begin ner's program , 1 06, 1 0 7, 1 08

--

969

l u mbar, 1 02- 1 09, 1 03- 1 08 obl i ques, 1 05 patient progression, 1 09 prescription p h ilosophy, 1 0 1 - 1 02 quadratus l umboru m , 1 03 , 1 04, 1 05 rectus abdominis, 1 05 torsion i n , 1 07- 1 08 , 1 08 transverse abdomi n i s , 1 05 Standard, defined , 936 Standing balance, one-leg, 764, 807, 807-809 Standing posture assessment for m uscular i m balance, 2 1 6-220, 2 1 8-2 1 9 assessm e n t of, 207 Statistical measures, 1 47- 1 48 Sternal l i ft , i n weight-tra i n i ng, 694, 694t, 6 95 Sternoclavicular j o i n t manipulation of, 502 , 504 i n respirat i o n , 5 5 3 Sternocleidomastoid neuromobil i zation tec h nique, 482, 482 post-isometric relaxation for, 440-44 1 , 44 1-442 tightness, evaluation of, 2 0 7 , 208 S t i ffness, in spinal stab i l i ty formu la, 1 00-1 0 1 , 1 0 1 Sti mulation points, 542, 543 Strength/endurance tests, 240-248, 240t grip strength , 2 4 7, 247-248 to reduce on t h e job back i nj u ry, 285 side bridge, 244 , 245 squats, 240-242 , 24 1 trunk extensor test, 244-245, 246, 246t tru n k flexor tests, 242, 242-244, 243t-244t Stress fractures, from pars i nterarticularis, 1 3 5 Stretching (See also Manual resistance tech niques (MRTs); Post-faci l i tation s tretch (PFS)) for dysfunction syndrome, 334-33 5 effectiveness of, 409-4 ] 0 sel f, 4 1 8 Subacute phase of care active care during, ] 9-20 chroni c i ty i n , 1 84- 1 8 5 , 1 85 Suboccip i t�s, post-isometric rel axation for, 439-440 Subscapularis , post-isometric relaxation for, 448, 448 Subtalar joint, m a n i pulation of, 505, 506 Supine fly exerc ise, 6 78 Support reaction reflex, 5 3 7 , 537 Suprapubic reflex, 536, 536 Supraspinat us, post-isometric relaxation for, 446-447 Surgery cervical fusi o n , 92 7-928 on cervical spine, 926 lumbar fusion, 927 on l u m bar spine, 92 5-926

970

--

Index

Surgery (contd. ) m i c rodiscectomy, 927 outcome risk factors, 926-92 7 overe m phasis o n , 78-79, 7 8 t post-surgical managemen t , 92 5-929 conservative care, 9 2 5 , 9 2 5 t postoperative, d i agnos t i c triage, 1 3 5- 1 3 6 postoperative activity restrictions, 927-92 8 rehab i l i tation, 92 8-929 spinal fusion, 1 3 5-1 3 6 spinal s tenosis decompression, 927 Syndrome X , 7 3 1 -7 3 2 Synergist substi tution, 3 6 Tac t i l e perception assessment of, 403-404 exteroceptive therapy and, 403-406 of foot, hand, and mou t h , 405 i ndividual character of, 406 mod i fy i ng, 404 muscle tone and, 403 scar sen s i t ivity and, 404-405 Tapi ng, in B rugger method, 3 6 6 , 366 Tarsal j o i n t , manipulation of, 504, 505 Teeth , brushing, 307, 308 Tem porom andibular joint syndrome, case study, 8 7 8 , 8 78-879 Tenderness, superficial, in Waddell non-organic low back pai n signs, 1 9 1 - 1 92 , 1 92 Tendomyosis, B rugger defin i ti o n , 3 5 5 Tensor fascia latae post-isometric relaxation for, 425-426, 426-42 7 tightness, evaluation of, 208, 2 1 0 Tensor technique, i n neuromob i l i zation, 483-484 Teres m ajor, neuromo b i l i zation tec h n i que, 479, 4 79 Test-retest rel i ab i l i ty, 1 48 Thera-Band use, i n Brugger method, 3 6 1 , 362-365, 363 combi ned exercise, 365 finger flexors, 363 goals of, 3 6 1 h i p rotators, 364 phases of, 3 6 1 plan tar flexors, 364 shoulder rotators, 362 t h igh adductors, 3 64 tru n k flexors, 362-363 Thigh adductors Thera-Band exercise for, 364 tight ness, evaluation of, 2 1 0, 2 1 1 Th ixotrophy, 409 Thomas test , modified, 233, 2 3 3-234, 765, 8 1 8 , 8 1 8-8 1 9 Thoracic fascia, soft tissue manipulation, 3 94 , 3 95 Thoracic spine l ocomotor [un c ti o n development, 5 5 0-55 1 post-isometric rel axation for, 4 5 2-45 3 , 453-455

Thoracolu m bar region, manipulation of, 500-50 1 , 501 Thorax, l i ft i ng o f w h il e brea t h ing, 788-789, 789 360-degree rollover, i n p hysical performance test battery, 2 6 3 t , 265 Tibia, pes anserinus of t he, 398 Tibiofibular joint, manipulation of, 507 Tightness weakness, 204 Tissue damage disc a n n u l us, 97 disc nucleus, 97-98 endplate, 97 factors t h a t affect, 95-97 i njuIY pathways, 98 instab i l i ty and, 98-99 ligaments, 98 neural arch, 98 process of, 98 shear i n , 95 stab i l i ty and, 94-97 twisting i n , 95 vertebrae, 97 Ton i c muscles, 3 7 , 38, 204-205, 783 development of, 545-548 l i st i ng of, 539t nature of, 533 Topical analgesics, 920 Torsion, in stab i l i zation exercises, 1 07- 1 08, 1 08 Torsion i nj ury, spinal pain related to, 1 1 8 Tortico ll i s antalgia, cervical, McKenzie approach for, 348-349, 348-34 9 Total Qual i ty I mprovement (TQI), 9 3 5 Tra i n i ng psychology of, 6 1 5-6 1 6 specificity principle for, 6 1 4-6 1 5 Tra i ni n g specificity, functional stab i l i ty trai n ing and, 6 1 4-6 1 5 Transfats, 734 Transversus abdom i n i s assessment of motor control, 598-599, 598-600, 600t in spinal motor control , 587, 587, 5 89-590 stab i l i zation exercises, ] 05 Trapezius m i ddle, manual resi s tance tec h niques for, 453, 45 5-456, 456 upper neuromo b i lization technique, 482, 482 post-isometric relaxation for, 43 6-437, 43 7-438 Trauma, spinal pai n related to, 1 30 Tread m i l l test i ng, of aerobic fi t ness, 2 5 3 Triceps surae, t ightness, eval uation of, 2 1 1 -2 1 2 , 2 1 3, 2 1 4 Tricycl i c antidepressan ts, 922 Trigger point i njections, 923 Trigger poi n ts

Index

chain reactions and, 780 defined, 4 1 2 , 532 motor patterns and, 56 1 -563 soft t issue manipulation of, 392 Trun k curl-up, movement pattern test, 2 1 4-2 1 5 , 215 Trun k extensor strength/endurance tests for, 244-245, 246, 246t, 766, 828, 828-82 9 isometric, 246, 24 7 Ito's, 246-247, 247t Trunk nexion agi stic-eccentric contraction approach for, 3 5 8-3 59, 359 endurance test, 766, 832 in physical performance test battery, 2 6 3 t , 264 strengt h/endurance tests for, 242, 242-244, 243t-244t Thera-Band exercise for, 362-363 Trunk muscles recru i tment patterns i n low back pain , 33 in spine stab i l i ty, 3 3 Tru n k rotation agist ic-eccen tric contraction approach for, 359, 359-360 restricted, chain reaction, 789 Twisting, in tissue damage, 95 Tying shoes, 307, 309 U l nar nerve bias, upper l i mb neurodynamic test , 476-478, 476t, 4 7 7 Undue hardship, American with Disabil i ties A c t defin i tion, 282 U n iversity of P i t tsburg, low back pain classification, 799-800, 800t, 80 1-802, 802 U pper crossed syndrome, 40, 42, 205, 206, 858-860, 859t Upper extremi ty ou tcome assessment for, 1 5 6- 1 5 7 , 1 7 5- 1 76 pain in diagnostic triage, 1 32 neurophysiologic factors i n , 46 Upper Extremity Function Scale ( U EFS), 1 5 7 , 1 7 5 U pper Extremity Functional I ndex ( U E F I), 1 57 , 1 76 Upper l i m b neurodynamic tests ( ULNT), 4 7 2 , 474-477, 4 76-4 77 brachial plexus, 477-478 1 - m edian nerve bias, 474-476, 4 76, 476t, 478 re-evaluat ion , 483-484 2- u lnar nerve bias, 476-478, 476t, 4 7 7 2- radial nerve bias, 476, 476t, 4 7 7, 478 Upper trapezius, tightness, evaluation of, 205, 2 05 f, 207 U rogen ital system, yoga-based exercises for, 582-5 83

-

971

Val i d i ty of employme n t screening, 2 77-2 78 o f outcome assessment tool , 1 48 of p hysical performance test bat tery, 2 63-266 Vele's reflex s tab i l i ty test, 764, 8 1 0, 8 1 0-8 1 1 Vertebrae, damage to, 97 Victoria Work Cover Authority, Austral ia, evidenced-based practice, 754-75 5 Vietnam Veterans Readj ustmen t A c t of 1 974, 2 8 0 Visceral c h a i n s , 789-790 Visual synki nesis, 4 1 6-4 1 7 Vlee m ing's active and resisted SLR tes t, 765, 820, 820-82 1 Waddel l non-organ ic low back pain s igns, 1 34, 1 34 t , 1 89- 1 95, 1 92- 1 94 distraction, 1 9 1 - 1 93 , / 93 overreaction, 1 9 1 , 1 93 - 1 94, 1 94 prognosti c valu e of, 1 90- 1 9 1 regional disturbances, 1 9 1 , 1 93 , 1 94 simulation, 1 9 1 - 1 92 , 1 92, / 93 superfici al tenderness, 1 9 1 - 1 92 , 1 92 Walk, p hysical performance test battery 50-foot , 2 6 3 t 5 - m i n ute, 2 6 3 t W a l l ange l , 6 3 8 , 638, 76 7, 864, 864-865 Weight s h i ft , i n weight-tra i n i ng, 694, 694t, 6 96 Weight-tra i n i ng, 6 88-7 1 1 alignment positions for, 694, 694t, 6 95-6 9 7, 696-697 fi tn ess components, 690-69 1 , 690t free-weights, 703-708 barbell l unge, 6 9 7, 705-706 barbell row, 704, 704 dead l i ft, 707-708, 708 dumbbell row, 704, 704-705 for explosive power, 706 good morni ng, 6 95, 705 hang c lean, 706, 706-707 overview, 703 power clean, 707, 707 special concerns, 703 squat, 705, 705 mac h i ne exercises, 697-702 abdomi n al m ac h i ne, 702, 702 back extension, 699, 699, 700 cable crossover, 698, 698 l ateral pull-down, 697-698 , 6 98 low pulley spinal rotation, 70 1 , 70/ pulley c runch, 702 , 703 rotary torso mac h i ne, 70 1 -702, 702 seated rowing, 6 96, 699-700 single arm pul ley row, 700, 700-70 1 methods for, 69 1 -692 overload i n , 690 overview, 689

972

-

Index

Weight- trai n i ng, (contd. ) plyometrics, 708-7 1 1 leg raise t h row, 7 1 0, 7 1 0-7 1 1 w i t h med i c i ne ball , 709-7 1 0, 7 1 0 overview, 708-709 with punc h i ng bag, 709, 709 postural alignment for, 693-694 pre-exhaust trai ni ng, 69 1 preparation [or, 6 89-690, 689t safety Fac tors, 692-693, 693 t split rou tine, 692 W h i plash (See Neck con d i t i ons) W h i pl ash-Associated D isorders ( WAD), Quebec guide l i nes, 2 0-2 1 , 2 1 t, 8 54-8 5 5 , 8 5 6 t W L-26, 1 60, 1 60t Work APGAR, 1 6 1 Work disab i l i ty mode l , 9 , 1 0 Work Loss-26 , 1 60, 1 60 t Work-related factors, i n l ow back pai n , 5 8 Work status, outcome assessment for, 1 50t, 1 59- 1 60 Working Backs Scotland, 7 5 7 World Health Orga n i zation ( W H O), I nternational C l assification of Functioning, D isabi l i ty, and H eal t h (ICF), 7-8 , 1 0, 227 Wrist, outcome assessment for, 1 5 7 Wrist flexors, agistic-ecce ntric contraction approach For, 3 5 8 , 358 Yel l ow flags assessment form for, 2 0 1 -202 assessment 0 [, 1 88-1 95

i n biopsychosocial model, 8 2 , 85-86 c hronicity and, 59, 60t, 1 84 i n diagnost i c triage, 8 2 , 1 27- 1 2 8 scree n i ng for, 1 8 8, 1 90t, 1 96 treatment of patients wi t h , 1 95- 1 96 Yoga-based tra i n i ng, 5 66-5 83 abdominal exercises effect of, 579 i ns tructions [or, 580, 580-582 , 58 1 pelvic floor exercises effect of, 582 for Levator Ani, 5 8 2 for perineal m uscles, 583 for urogeni tal system, 5 82-583 posture and, 567 respiratory exercises effect of, 568-569 for lower abdomi nal breath con trol, 569-57 1 , 5 70-5 7 1 for m iddle breath control , 5 7 1 -5 7 3 , 5 72-573 for normal motion, 569, 5 70 for upper breath con trol, 573-5 74, 5 73-5 74 for whole-breat h con trol, 576, 5 76 spinal exercises effect of, 5 7 5-576 supine, 576-578, 5 76-5 79 Zygapop hseal joint di scography of, 1 4 1, 1 4 1 - 1 42 spinal pai n related to, 1 1 8, 1 4 1 - 1 42 Zygapophysial j o i n t , diagnostic block 0[, 1 1 5 index

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